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I <br /> RECEIVED ' <br /> - �/4. dam, �� JUL 2 4 Z015 gefety end.Butldings Cllvlslan: County. Dane <br /> �} u ` 201 W.'Wachinglon Ave.,P.O,6ox'7162 • •tanllnry r eriniUNumlier la ba tilled to by ca;) <br /> I. N. g, Public Health MDC •Madison,WI 63707-7162 <br /> �t.,�!'.4 s� � Environmental Health 13 -261 C— Oc 2 q 2- <br /> ' <br /> 'Sa + <br /> nitat Permit Application Stoic lronsdeilanNumber <br /> y•In accardnncewlth•$l'S 303.31(I);Wis.Arlin.,Cock submLssion of this fonn.la lite appropriate goveminental unh . <br /> . is:requlnd.prier to obtaining u sunbnry pennh Nate.Application runns rcratnte awned.PO\VfS are submitted to: Project Addinss(if.811'fcrcgh,lhan;mallles'utddtess) <br /> the Depurlmnerit:orSafety arid ProfessiMial Sen'its„Prrsppal;)itfonnal(an you-provide.may ha:used.rorsecuadnfy <br /> .purposos.ln accarilbnee with Omit/twos Law,s.i3,tTQi)(m)I•Stats.. Flyhawk Lane <br /> ..1, Applinatintr:liiforiitntlon.=Pieitio'PNntAlllrtforinntinii • <br /> • Properly Olv_ner's:Name • Patbcl S <br /> Encore Construction Inc,(Tracy&Jill Wimer) 0907-183-6198-0 <br /> Property thvncrts MallingAddiess Propaty.Lociitloii <br /> 6840 Schneider Road .. . 'oovt.Lot <br /> Y' p SE .5, SW "!i<:.,SecIlon 18 <br /> 1711 ,Sialo � Zi :Code Ph"o'ngNum�cr <br /> Middleton,WI 62 .(cirbiceno).• <br /> H.Type or Rultding(chaek all tttnt.npply') ( Liu — T. 9 N; n.7 SA)?W. <br /> HI lop.Tamil.Dwelling-Ntimber.nfDedroottts 28 'SubdivisionNania <br /> Model/ . Slackhawk Fields <br /> 0 P ubilc/Comriterclot-Pesh.'ribc Ike <br /> ❑CiIY or ......_. <br /> CSMNumbm .`0 Village or .. <br /> 0 Slate owned'-beset-the Usu. <br /> 0 <br /> on or Roxbury <br /> fir`Type of Permi:`[ChpCc Only one Ia bn9ua A.•Complete•Slo B if d pp lieabie)•,1• ..g tap ®.6lhectvladlticellan to Ex(.sling Sysicrn(explain) •• <br /> ❑.Nnty System °0 Rcptaccmcnl System �'trealmantlfloldin Turk Tl, lecemanl OHfy ) <br /> , - Reconnection To Community Systeml•U, 0'Permil licnewal :0 Permit itevistan . 0 Change orl?lulnbar L�Parmil Trone(crta Neal l:isl Previous Permit Number.and Dutelssabd <br /> pufotitC.ypltbltou •Owner <br /> I V.Tyner of POWTS System/Conipnrit:rit/Deviem.(Cituelcnit flint apply) • <br /> . 0 Non.Pnmssudzed In-Ground 0 Pressuriacd lrnGraund 0 At-Grade El Mound?i4 in..orsuitahlesoil 0 Mound<21I:1n.,ofM ablesail. <br /> ❑Holding Tank 0 Other Dispersal Caolpwtent(aspipin) 0 f relieatlnant peVlca(0011111) . .. <br /> V.DI spersnlffren tntant:/1ren.infarninfditi . .._ . . ...........,.... <br /> DeslgifFlow(god) Design Soil Appllcalton Ithte(gpdsQ• Dlspersai.Arca;ltequlred.(a) . Dispersal Area Promised(al) Syslegygttogtion <br /> VI.Tmdr Info Capacity.:ln; Total • it or • Munutbeturer • • <br /> Ga))ons : Callan, Units S It. v <br /> •New Tanks eauthoaTonks 1 U A <br /> .o.'t� o N • Is O r% • <br /> -Sepik or l lutdlon Truk. <br /> Dosbu chamber • <br /> VII.Rosponstbilily Stntement-I,llte.undcrslgacdi aislimerespansibtlity;rorinstalialtannrtha POWTSShawn un the allaehadplans. <br /> Piilumber'stloma(Print) Plumber's h1P/MPItS•Number •business:PbaneNumber <br /> .l`tb(..-1-N -' v,-afk 7.4,It? ._ cs ._ J';2 d'%a? <br /> Plumber's Address(Sirant,CITY.Stale,Zip Code) <br /> County/Department Use Only ....,./.._ �' <br /> nnmted ❑Disapproved T Tell Fee `e Dalo lssuel Issuing tSignalure ',(�, <br /> •�'OWito-Given Reason Ibr DMol S ` 7'28/` �� i�'" °_'' <br /> IX.Conditions of Approvnl/Ransons for Dlsnpprovnt <br /> AMC!'In complete pawns for Me lvinnr and submit to the Cnanly only en paper Wien time H Ili e•11 Inches in the <br /> 51:10,6398(iL 11/1 I) <br />