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Generated by PDFKit.NET Evaluation <br /> 001. merce.W11.90V Safety and Buildings Division OU // <br /> 201 WBURNETT <br /> W.Washington Ave.,P.O.Box 7162 <br /> iseons n Madison, 53707-7162 `f an,'rtagnn Firm dN ber(tobe 1 m y o. <br /> areas7o lOS 7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.8321(2),Wis.Adm.Code,submission of this form to the appropriate <br /> governmental unit is requited prior to obtaining a sanitary permit. Note:Application forms for state-owned Project Address(ii differrin than muling address) <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may be used for <br /> secondary purposes in accordance with the Privacy Law,s. 15. 1 m,Stus. 28995 Tallmo n trail <br /> I. Application Information-Please Print AN Information Parcel# <br /> Property s Name /y 012 9675 04900 <br /> Eugene Montandon / ail :� Property Location <br /> Property Owners Mading W Gov[.Lm <br /> 28995 Talimoon trail Y� �/` Section 11 <br /> City,StateZip Code Phone Number (circle one) <br /> EorW <br /> Danbury WI 54830 (715)2593654 T 40 N; R 5 C t: <br /> IL Type of Building(check all that apply) l,pt# Subdivision Nam <br /> (e 1 or 2 Family Dwelling-Number of Bedrooms 3 Block# <br /> C Public/Commacial-DescribeUse Coy <br /> r State Owned-Describe Use CSM Number Village Jackson <br /> (: township o <br /> III.Type o Permit: (Check only one box on fine A. omplete fine B if applicable) <br /> C New System (i Replacement System ('Treatment/Holding Tank Replacement Only Other Modifica ion to Existing System <br /> B. r Permit Renewal r Permit Revision r Change of r Permit Transfer to New List Previous Penn it Number and Date Issued <br /> Before Expiration Plumber Owner <br /> W.Type of POWTS System: (Check all that apply) <br /> 9 Non-Pressurized In-Ground r Pressurized In-Ground F- At-Grade r Mound>24 in.of suitable soil <br /> Mound<24 in.of suitable soil <br /> F Holding Tank r Other Dispersal Component(explain) F Pretreatment Device(explain) <br /> V.DispersaVlYatment Area Information: <br /> Design Flow(gpd) Design Sod Application RaWgpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) 3ystern Elevation <br /> 450.00 0.70 642.86 661.00 3-17 <br /> VI.Tank Info Capacity in Total Number Manufacturer c <br /> Gallons Gallons of Units V Lia <br /> Teaks TaDkseoks <br /> Septic orHoklingTank 800 800 1 Skaw Pre-Cast r r r <br /> Dosing Chamber r r i- <br /> VD.Responsibility Statement- 1,the undersigned,usame ropendbinty for installation of the POWTS shown on the sun ched plain. <br /> Plumber's Name(Print) PI s�jg MP/MPRS Number Bus ass Phone Numb« <br /> Ross Tollander f 851954 (715)866.8070 <br /> Plumbers A (street,utty,state,Zip o e <br /> 27220 Jamison rd,Webster,Wl 54893 <br /> VIII.Coanty/Departmeat Use Only <br /> Approved Disapproved Sanitary Permit Fee(includes Groundwater Du�Iwued4) Iss 'ng S' tamps) <br /> Surcharge Fee) �j <br /> Owner Given Reason for Denial {C �,J0 <br /> DI.Conditions of Approval/Reasons far Disapproval <br /> Aaa<h cewpkte plus(to the Caaaty only)l.rIlte system an paper not law than 81/2 e 11 inches in sue <br /> Click ftA-609MC*1 8[)lUS1tdN"01/09 <br />