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Sep. 15. 2009 3:54PM) t� kw u ti w' No, 1326 P. 1 <br /> r1nn�4 <br /> - commerc= _ov SEP � �zO�t�IJw Ri,o;ildings Division &ally <br /> r Ave..P.O.Box 1162 Dane <br /> iSCO - fl M 53707-7162 Sanity ' n' •un �. C. <br /> . Department of • memo---•:..-.- f,� <br /> �!i . <br /> Sa .., <br /> • <br /> 11'a % e; .1 1 I '11i n Slate rantac on N er <br /> In accordance ttirb s.Comm.10.21(21.Wis.Adm.Code.submiesint of Il s form to the appropriate go'eernmenial PA/Ye 'skill 7!7 d vg <br /> unit is required prior to obtaining a sanitary permit. Note: Applicatit n forms for stale-owned POW7S ore Project Address(if different(Ilan nailing address) <br /> submitted In the Derailment of Commerce. Personal information yo. provide may be used for secondary <br /> PWJOSes in accordance%cid)the Primacy Law.s.iSM4(1)(m),Slats. 7344 Mama Road <br /> I. Application Information-Please Print All Information <br /> Properly Ottner's Name Parcel if <br /> Mitchell Reible 0907-162-9000-5 <br /> Property 0wirer's Mailing Address - ' Property Location <br /> 7344 Inama Road <br /> Govt.T.nt <br /> City,Slant Zip Code phone Number SW 'y, NW ,A. Sectinn 16 <br /> Sauk City,WI 53683 608-393-9836 9 (ciucloone) <br /> 11.1 Type of Building(cheek all(fiat apply) w tat N <br /> T N; R 7 E or W <br /> IN I or 2 fanny Dwelling-Number of Maroon's 3 Subdivision Nome— <br /> `Block a 40.1 Acre Farm Parcel <br /> 0 Public/Commercial-Describe the <br /> 0 State Owned-Describe Use CS <br /> l Number ❑Village of ,-„ . <br /> i Tann of Roxbury <br /> , <br /> tn.Type of Permit: (Check only one box on line A. Complete ine II if applicable) 1 <br /> A. 0 New System 8 Replacement System 0 Treatment/I.nlding Tank Replacement Only 0 Other'Modification to Eliding System(explain) I <br /> 0. 0 Permit Renewal Q Permit Revision 0 Change of lumber 0 Permit Transfer to Nen' list Preykn�s Permit Number and Hate Fssucd <br /> Aaron FApiratittn Owner <br /> IV-Type of i'OWI S Si tam/ComponenUClevlce: (Check all th t apply) _ Y <br /> 0 Non-Pressurized 1mGeottnd 0 Pressurised fn-Grotmd 0 At-Grsd )Mound>24 in.orsottable soil ❑Mound.<N in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Die,eraalfl'rea(mcnt Area Informellon: <br /> Design flaw(grid► Design Soil AppTicntinn Rate(gpdsl) OisperMl tea Requited(if) Dispersal Area Proposed('Q System Elevation <br /> 450 0.6 410 456 96.67' <br /> VI.Tank Info Capacity in ■tel o of Manufacturer <br /> Cnlions Ga lens Units <br /> New Twits tsistIng Tanks 1 g CB g Y ... <br /> ..0 A `" cn w(7 a <br /> `codeocolir Tank 1000 1100 1 Wieser x <br /> !Wing Chamber 600 ~v _—. 610 1 Wieser x <br /> VII.Responaihifily Statement-I,the undasl ned,mistime responsi )lily for Installation of the POWTS'hewn on the attached plans. <br /> Plumber's Name(feint) PI n s Sign•or MPIMPRS Number Dusiness Phone Number <br /> eifiee GoPi i2 ,./ 2a,0 Le 9l _-08.4V -863 <br /> Plumber's-Address(Street.City.Stale.Zip Code) <br /> t bee tele yo, 0 411 '1 5 _1 ! _ ., /4/f 5-, 58'3 <br /> VIII.County/Deperimeat Use Only <br /> Xppprover! a Disapproved srnnit Fee Date Issued Issui A t Signs re <br /> 0 Other Given Reason file Denial •va, (' (_ 0 { ( <br /> IX.Conditions of Approval/Reasons for Disapproval �rf illottr— P�?�6€c 49,A 4 <br /> ...,_4 cAtt, F4A r - - , f e ,tthe 6 {`M�l�- > 4" %4-7 Vet v08 <br /> -"'l sec- W P1..^( I / . e • Av'c: 6. or /fir(, <br /> Athlete for ample leplsn fez the totem anti sub ra the COVMti only en piper not 1wehsn1 in*(lmcMeainsize <br /> r 3Sc V <br /> 0„\K- 52Lcn <br /> SIfl.639R(R.02/091 Valid that 02/11 <br />