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Oct. 15. 2009 8:28AM No. 1507 P. 1 <br /> tc rnm rce.wl.gov Safety and Buildings Division County <br /> ir 201 W.Washington Ave..P.O.Box 7162 Dane <br /> tS COf S'n Madispn,WI 53707-71(i2 San' N r(t 11 i ) <br /> Department of Commerce <br /> (J , 7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.R3.21(2),Wis,Adm,Code-submission of this form to the appropriate govemmental <br /> unit is required prior to obtaining a sanitary permit, Note; Application forms for state-owned POWTS arc -Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal inliormation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law',a, 15.04(1)(m).Slats. <br /> 1. Application infoe matiaa-!°lease 1?riltt All lafermation Old Stone Road <br /> Property Owners Name - - . <br /> Parcel N Tim&Chris Properties LLC(Tim Kottowski) <br /> 0510-223-9330-0 <br /> Property Owner's Mailing Address <br /> 3066 Shady Side Drive Property Location <br /> City. _.State - Govt Lot <br /> Zip Code Phone Number SW A SW �. <br /> Stoughton,WI 53589 Season 22 <br /> (circle one) <br /> II.Type of Building(check all that apply) Lot!! T 5 N. R 1U E or W <br /> el I or2 Family Dwefling-Number of Bedrooms, - 3 2 Subdivision Name <br /> Block* <br /> D Public/Commercial-Describe Use _ .- <br /> ❑City of _ <br /> ❑State Owned-Describe Use CSM Number []VI)lage of <br /> 12515 ®Town of Rutland <br /> IiI.Type of Permit! (Check only one box on line A. Complete line B if applicable) <br /> A' . <br /> New System ❑Replacement System ❑1 ealmenvHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 11. ❑Permit Renewal ❑ Permit Revision ❑Change of Pltmiber ❑Permit Transfer to New l,isr Previptg Permit Number and Date Issued <br /> Before Expiration _ Owner <br /> IV <br /> I <br /> .T of Fowls Srstem/Component/Device: (Check all that apply) - <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground ©At-Grade ❑mound,24 in.of Suitable soil ❑Mound a 24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) - 0 Pretreatment Device(explain) <br /> V.Diseerjal/i'rntmcat Area informations __ _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sr) System Elevation <br /> 450 0.4 1125 <br /> 1128 98.6' <br /> Vi.Tank Info Capacity in Total *pf Manufacturer ^— - <br /> Gallons Gallons Units ? <br /> -i a r� LI Nov Tmke Existing Tanks ` 3 a . v 1r <br /> n-V iji Fri <br /> C7 ii <br /> SCprid a Molding'fank 1000 1000 -- <br /> DnSin�(fumble --------_- <br /> 1 Dalmaray x <br /> 600 600 1 - Dalmaray x �'- <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P umbers Name(Print) P in bet's Signature MP/MPRS Number Bt iness Phone Number <br /> N�• � . \\' �� A_ as l • �' 4c,. fit -7. • '. <br /> Plumber-s Add *tract,City.Stale,Zip Code) <br /> VIIi.Coon IDs•artmetit Use <br /> Approved ❑ Disapproved Peemiit/PCC - Data Issued <br /> /� issuing A• •nature <br /> ❑Owner Given Reason forT)eniel $304•--- /of/T(Vq <br /> IX.Conditions of ApprovaUReasens for Disapproval <br /> Much to coropkle plans for the sywtcm and svhruit to the Calmly only o.paper not lea the■8 in:11 incite;in size <br /> DB- al if <br /> ch14- S `1 <br /> 5131?-6398(R.02109)Valid tint 02/11 <br />