Laserfiche WebLink
', ' '�- -, <br /> a la t P-4— 1;2A 1'iJ .' <br /> Commerce.wi. ,an ) uil;,dings Division County p <br /> 201 W.\Vashi i Ave.,P.O.Box 7162 DANE 1 P <br /> diso , V 53707-7162 Sanitary Permit Number(to be filled in by_Co.) <br /> 1SCe0hS` Jt � 1 8 2O �,,. ' 13 -/- v.ef.d' x,11/ <br /> . -- - State Transaction Number <br /> Sanit ryLPFt r �t 4-ppA atio E' i. 11 `,;,/ i 't , '. <br /> k �x. t'�.,t,: ,may <br /> In accordance with s.Comm.83.21(2) Wis.A Code,subn ttsion p,f 1)1 o1rt to tY ap fbpnate Jove the tdt_- <br /> unit is required prior to obtaining a tsanita�y permit. �1ote`. Applicatioh gr s or state-owned POWTS are p(o eCt Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you vide may be used for secondary : II <br /> purposes in accordance with the Privacy Law,s. 15.04(1}(m),Stats. 4 }I O 1 r1 ' ' - TIMBER LANE <br /> I. Application Information-Please Print All Information i <br /> Property Owner's Name i ! jParcel';N <br /> BRETT&MELISSA OFTENDAHL L- ;0708.183-9199-0 <br /> Property Owner's Mailing Address i '' Property Location <br /> .`1 _.__ <br /> 2865 INTERLAKEN PASS Govt.Lot - <br /> City,State Zip Code Phone Number SW '''A,SW '/,, Section 18 <br /> MADISON WI 53719 (Check One) <br /> II.Type of Building(check all that apply) <br /> Lot}! T 07 N; R 08 5 E ❑W <br /> ©1 or 2 Family Dwelling-Number of Bedrooms 4 <br /> 4 Subdivision Name <br /> Block ii <br /> 0 Public/Commercial-Describe Use <br /> (--'I� <br /> — I City of <br /> State Owned-Describe Use CSM Number ❑ Village of <br /> 12123 © Town of MIDDLETON <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. © New System ❑ Replacement ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> System <br /> B. ❑ Permit ❑ Permit Revision n Change of n Permit Transfer to <br /> List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV.Type of POINTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground El At-Grade SI Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(god) Design Soil Applica3ion Rate(gpdst) Dispersal Area Required(st) I Dispersal Area Propos cl(st) System Elevation <br /> 600 0.65 D) I Basal 1000 Bed 606- Basal 1650 8 660 96.0 <br /> VI.Tank Info Capacity in II Total #of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank 1286 1286 1 MEADE Prefab Concrete <br /> Dosing Chamber 800 800 1 MEADE Prefab Concrete <br /> VII.Responsibility Statement- 1,the undersigned,muffle r ponsibility fo 2tallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu ber's Stir ei MP/1rtPRS Number Business Phone Number <br /> STEVEN R.CROSBY -J 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DR. DANE WI 63529 <br /> VIII.County/Department Use Only -----' <br /> _ Approved _ Disapproved Permit Fee Date I sued • issuin gent tgn lure <br /> _Owner Given Reason for Denial $}{{�{,J a% }7,R3 /j/ �` <br /> L' Conditions of ApprovaVReasons for Disapproval `[ ,` /�f \\ <br /> Attach to complete plans f o r the system and submit to the County only on paper not Less than 8 to x I I inches in size <br /> ( <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />