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444,13''' �w�`�.►, Dane County Human Services Dept = % d' <br /> .�° Public Health Division :4 FV\''- <br /> Environmental Health Section <br /> °' 1202 Northport Drive Rm 154 <br /> DANE COUNTY <br /> unntssiener OF MIKAN SEM= Madison WI 53704-2088 <br /> Ph: 608.242.6515 Fax 608.242.6435 <br /> r _ <br /> PRIVATE ONSITE Date R ceivgd— <br /> WASTEWATER SYSTEM - POWTS ' <br /> I MAR 16 ;C <br /> PLAN REVIEW APPLICATION • <br /> Property Owner Name ' 'a ' <br /> (�1i !L¢. 4 I ra.c !"TtV YY► ck.✓1 Sc)r") C/o /, e. a /c-wS <br /> Owner Mailing Address <br /> 0 8 5 I e,..Ln <br /> City • State Zip <br /> t,-n Pry... is w; . .53590 <br /> Property Location -SE V, me in T 9 N R // E Section 3o <br /> Town of 2c,sfp/ 4 9/(-- .30/ — 38/ —3 <br /> Lot 6/ Subdivision/CSM 5 <br /> Property Address(if different than above) City State Zip <br /> Building Use:(check all that apply) <br /> 0 Public/Commercial(maximum 5,000 gpd) �'for 2 Family 0 New 0 Replacement <br /> Type of POWTS <br /> A. Treatment and Dispersal Systems <br /> 0 Pressurized In-Ground 0 At-Grade Mound Mound 0 Drip-Line <br /> ❑ Aerobic Treatment Unit 0 Single Pass Sand Filter* 0 Split bed Sand Filter* 0 Recirc Sand Filter* <br /> *Sand Filters up to 2,250 gpd only, all others up to 5,000 gpd Total GPD (O O Feed/9 5, 00 <br /> B. Collecting and Holding Components <br /> 0 Holding Tank (pre-cast or approved mfg.only) Total GPD Fee <br /> Designer Information $f MP/MPRs <br /> ❑Designer <br /> Name f3notrc4.., W. °Arming Credential# c;go/45- <br /> Address 6 @0-1 C.TM " C" <br /> City Wa i c.1-tc CO,. c 3 557 State LJ► . Zip s 3sy-7 <br /> Phone (6n8 ) 83i— Bao3 Fax (608 ) 831—€(o7 Ce1Ph (66z) <br /> MSWord/Forms/Co Plan Rev Appl.doc 5/03 <br /> Fee Schedule on Reverse Side <br />