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Couoty <br /> / -;;�,.� Safety and Buildings Division Dane <br /> M6 <br /> , 201 W.WasIdr�n Ave..P.O.Box 7962 Sodkry Permit Number(lobe RMedin by Co.) <br /> i .qz Madison,WI 53707--7162 ' -20'_�_ <br /> Od33(c <br /> Sanitary Permit Application Stale Tra amctiunNumber <br /> lo accordance with SFS 383.21(2).Wa.Adm.Code,submissiondlbk a the appropriate pommelled unit <br /> Is rewind.prior toobtainio0sikaypenal.Note:Application Fords for sWe-ovvned.POWlSmsoIndltedto Project Addrcs a(Hdtrfetaa Poo mailing address) - <br /> tbeDeputes*of Safety and Profm(oml Scmies.Pianos!htfrmsdoa.yoe provide may be used for spry <br /> Man=lnsxrd®oe with the Privscr Law,s.I5AI(9)(m).Stars. 1915 N.Kollath Road <br /> I.AppOeaflonlnimfmtflen-Meter PrintAtilbfonaaHes <br /> ?!err +r •Na,e S <br /> YAM /17/4 tr 0607-264-9330-9 <br /> Property Owner's Wiling Mims / Property Loaders <br /> 3610 Country Grove Drive GOvt.Lot <br /> say,Sate (ode Plane-Plumber SW u, SE Y,,Section 26 <br /> Madison,WI 719 4694799 T 6 N R 7 (ti E <br /> II.Type of Building(check dl that . ∎) loll <br /> i I a2 Family Dwding-Nwnbe :- <br /> • 3 Subdivision Name <br /> Block,! 4.13 Acre Metes&Bounds Parcel <br /> ❑PubltaCammraw-nesedbe Use ❑Clop( <br /> owad-Dner iboUec tSd <br /> ❑Sate Nember ❑Wage or. <br /> I Tarn of Springdale <br /> III.Type of Pointe(fated[only one°lwzon Hue A.CoapkteNee B if spplteabie) <br /> " l New sy pan ❑Repleccment:System ❑Treetnentiliobilias Tads Repko nnem Only ❑Other Modification to Fs:sisals Srslmoi ) <br /> S. ❑Permit Renewal ❑peon!Revision ❑ri,m>aof pk®ber ❑Pmmh Trenaferm Nee tad Previous Pemdt Nr ibersod Done issued <br /> Berme Espirtiao Owner <br /> IV.Type of POW TS SystemlCOmponendDevhrc(Cheek sill thatappiy) <br /> ❑Nan-PresavimdIoLmuad 0 Pressurized la.Omtmd ❑AM.Qorde &Moaod>24 in.emulsible s it 0 Moundc24 in.of suitable soil <br /> ❑Holding Tank ❑Caber Dispose!Component(esp40 ❑rraRamsrs Device(explain) <br /> V.DlspersuVrreatment Area Information: <br /> Desna Few fgpd) Design Soil App! Basdgpdd) Dkpaml Ate, ad(50 ( nal Area Propased Sygeafkwtim <br /> 450 1.0 O.(o 450/7S* 456/ / 96.5' <br /> VI.Tank Sole r is Tod B of Mrwfsrmer <br /> Genera Gallons links _ �° <br /> New Tanks Wain Taela L'1 g B i °i <br /> U w,.. iz M t7 ii. <br /> Setae echielaherair 1000 ....... 1000 1 Crest x <br /> Dosing Chamber 600 600 1 Crest x <br /> VII.Responsibility Statement-I,the u:... - _..".,:::. be Installation ef h o <br /> b � POW IJSQ�.the atiatbd plans. <br /> PI��s Mad(Print) 'V s.... / Number Brsoa <br /> s�Phone Numbs <br /> (VOwXS .4 .. 1 1r . 2 YZ '- 9/ <br /> 4' <br /> Plumber's Addms(Sued,Ci�ry.Sea Pr <br /> ` ( / L e 2 -4% . -� J-v <br /> VIII.ConmtylDeperhneet Use Ouly <br /> Permit Fea DOD'sued <br /> fs ewr'°""' ❑Owner Given Reason f o r D e r a i l 410 /346-lair- K X14114— <br /> IX.Conditions of Approval/Reasons far Dlsappr f <br /> s� pGAnr ct.{. b pop it 35 7C 7s - <br /> --, ?�T�T filowea 'ti ' 4ff AivO 4A "f T oa�wr��E� <br /> 0- fore Col rlIc-7y JwL EEV)Yp9 * 41-6) 1/6°c`1444 -7-4411Fit, <br /> Attach tsesmpittepima for tarspoo pad=Mat tetaeCooly only as paper mat loo flay Swell fades Is she <br /> SBD-6398(R.11/1 1) <br />