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Aug, 26. 2009 12: 54PM ���li. l� L`' " '' `� No. 1212 P. 1 <br /> Commerce.wf YI AA 'ji and rl 'gs Division County <br /> AUG/1UV 4 - t•.thing o. a P.O.Box 7162 Dane <br /> ' iscon `1f Madi,m, 1 5.707-7162 Sa um b illedCo.1 <br /> Department Of Com• ems - Pu,plic Health MDC _ <br /> Sault 1 _. l_ 'i! :`• i i'r e -• -i State Transaction Num <br /> in accordance with s,Comm.83.21(2).Wis,Adm.Code.submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitery permit. Note: Application forms fur stalc•mvrtcd ?OWTS are Project Address(if different than mailing address) <br /> submitted to thy Department of Commerce, Personal information you provide may be used for secondary <br /> • ••sex in accordance with the Privacy Law,s.15,04(1)(m),.Stats. Happy Valley Road <br /> I. Application Information-Please Print All information <br /> Property Owner's Name Partei f! <br /> David Baehr 0911-213-9080-0 <br /> Property Owner's Mailing Address Property Location <br /> 924 Parkview Drive <br /> Govt Lot <br /> City.State zip Code Phone Number SW y,, SW A. section 21 <br /> Sun Prairie,WI 53590 213-6686 (circle one) <br /> iI.Type of Building(check all that apply) Lot H T N; A 11 E or u' <br /> 2 I or 2 Family i welling-Number of Rechnrms. 1 Subdivision Name <br /> Biock>r <br /> ❑PublidCommercial-Describe Use <br /> d City of <br /> ❑State Owned-Describe Use CSM Number C Village of <br /> esc <br /> 11815 ti Towtim or Bristol <br /> iiI.Typeii6.Check only one box oe line A. Complete line B if applicable) <br /> New Sysle I• ❑Replacement System C Treatment/Holding Tank Replacement Only ❑Other Modifce tion to Existing System(explain) <br /> I ❑Permit Renewal ❑Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> IV.Type of POP/TS System/Component/Device: (Check all that apply) <br /> a Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Oracle ❑Mound`24 in,of suitable soil ❑mound<24 in.of suitable soil <br /> Q Hnlding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal Treatment Area Information: <br /> Design Flow(god) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Din sal Area Proposed(sf) System Elevation <br /> 750 0.4 1875 1896 91.4,92.0,92.3,93.0' <br /> VI.Tank info Capacity in Total to ut Manufacturer <br /> Gallons gallons Units da ;: a r <br /> New Disks ExistingTnnkc z g _ . <br /> a 1 <br /> c.V rn n 71 iL t7 a <br /> fi-S — Holdinit Tsnk '1600 1600 1 Crest x <br /> r)esing Ch,n,t,er 800 y 800 1 Crest x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWYS shown on the attached plans- _ <br /> Plumber's N3ame(Print) ' Plum./• s Si- attire MP/MPRS Number Business Phone Number <br /> 111-01)pe,} . o..9s� ANN., . . 717i— 6Qr G 1 .y o <br /> Plumber's Address(Street,City.State,Zip Code) �O t ND OaL °f eel t r4 J ,.. _ 'ri <br /> VIII.Coen /De•amen!Use On " I <br /> Approved ❑ Disapproved <br /> Permit Fee Date Issued Issuing,. � <br /> ❑Owner Given Reason for Denial S 3(4.00 �1 I r .-�+`�_ <br /> IX.Conditions of Approval/Reasons for Disapproval f/ <br /> Attach h complete plan%far tie rystem end n061'44(10 the Co■etx only on paper not aces th»S to x I I iaebtn in ieee <br /> 6/ 1) <br /> Chli—51 y-,t <br /> silo-6398(R.02/09)Valid lhru 02111 <br />