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j ts �J �icu' u ► <br /> ' commerce wi �r �i <br /> B,, i ,S 201 W.Washin J'3707_7162 e.,P.O.Box 7162 <br /> 1 COfla I r tson Sani cr 'n Co.) <br /> Department of Corn i' li <br /> �,-};-A State Transaction Number <br /> Sanit. y lRl9t i , i®1: <br /> In accordance with s. Comm. 83. 2 WEnmistanrosdelaidbj i ltihtt of thi• form to the appropriate 48557 <br /> governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned Project Address(if different than mailing 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. 15.04(1)(m I),Stats. CI-El "J" <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# ?0-70 —0 <br /> Greg and Mary Rees 0706_263_$ 0-i - <br /> Property Owner's Mailing Address Property Location <br /> 4901 Fore Trail <br /> Govt.Lot 1 <br /> City,State Zip Code Phone Number . NE ',4, SW IA, Section 26 <br /> Middleton, WI 53562 608 437-3068 (circle one) <br /> 11.Type of Building(check all that apply) T7 N; R6 - E or W <br /> 1 Y) Lot# h <br /> 1 or 2 Family Dwelling-Number of Bedrooms J Subdivision Name <br /> Block# voo��� CSM <br /> Public/Commercial-Describe Use <br /> City of <br /> CSM Number Village of <br /> State Owned-Describe Use /1 1 rrr111 <br /> I (l f r' Town of Vermont <br /> DI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Replacement System Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. Permit Renewal Permit Revision Change of I Permit Transfer to.New List Previous Permit Number and Date Issued <br /> Before Expiration, Plumber Owner - <br /> IV.Type of POWTS System/Component/Device: (Check , • .•• <br /> Non-Pressurized In-Ground Pressurized In-Ground e o and > 24 in.of suitable soil Mou nd < 24 in.of suitable soil <br /> Holding Tank Other Dispersal Component(explain) Pr e treatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.6 750 750 100.0 <br /> VI.Tat11c Info Capacity in Total #of. Manufacturer <br /> Gallons Gallons . Units o <br /> New Tanks Existing Tanks w g . `6 d ,s_ n <br /> aU v, H .) 'w c,- n. <br /> Septic a 44 ling Tank 1600 -- 1600 1 dual Crest X <br /> Dosing Chamber 800 -.- 800 1 Crest X <br /> VII.Responsibility Statement- I,the undersigned,assume respons' idly for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P1 'a Si_"attire/ 'II MP/l fPRS-Nun tn" Business Phone Number <br /> Mike O'Connell f�1 S 659 608 437-3068 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 102 W Main Street Mt. Horeb, WI 53572 <br /> VIII.County/Department Use Only <br /> �Ap roved Disapproved Permit Fee ' Date Issued Issuing nts' to <br /> Owner Given Reason for Denial-, $ UOO' le—/9' <br /> IX.Conditions of-Approval/Reasons for Disapproval <br /> `�- S �7t v1 1 c v/!4i2.I /r14(I(vl1G I4, ' /�'1 t/t�r `M (1 /.4i/, <br /> ih G! ANTING THIS,APPROVAL, DAVE GQUNT <br /> tN4/iRQNf�RENTAL HEALTH DQES NQT HOLD ITSELF <br /> LIABLE FOR ANY DEFFCTc? tar n�y�..-. ..� <br /> Attach to complete plans for the system and submit to the County only on paper nbel .t aii'tAkCii � re "vn JrEUtI-t(iA- <br /> n a �, EXAMfNATIONOVEiT- <br /> DA_�� Ata 1 SIGHT, CONSTRUCTION OR ANY DAMAGE TyAT MAY <br /> RESULT IN OF AFTER INSTAL!AT,�7(til n <br /> SBD-6398 R.02/09)Valid'thru 02/11 THE RIGHT TO ORDER GHANG N ,'RE ROES <br /> tA'N\ ' �j r_ % SHOULD CONDITIONS ARISE{1 S Q ADDr;fQNs <br /> 1 NECESSARY. Ifu TL'lS <br />