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0004'''.... . '') <br /> • <br /> ,�--- County <br /> Safety and Buildings Division Dane <br /> :fp s0:.^34r,11, 201 W.Washington Ave,P.O.Box 7162 smawy Permit Nmaba no be Wkd in by Co.) <br /> 1 <br /> s S'"y-� f�Nt <br /> i t ' Madison,WI 53707-7162 • <br /> 3-21b-0(103o <br /> Sanitary Permit Application Slater Transudes Number <br /> lo uccnidmics with SPS 313.21(x),Wis.Adm.Code,submission of this Rem to theoppoprinte governmental unh Trans.ID 2662088 <br /> _ - is reached priorto obtaining Lusher ry pent_Nom Application m farms for stote•avia d POWTS use submitted to Project Address of dI feeml then totaling address) <br /> the Depmnoau of 5akty and Arokisional Service.Pasaeal informatics you provide may be used for secondary <br /> mimosa in accordance with the Privet'Law,s.ISAA(I)(m).Slats. <br /> L Applicati onInf orniefos-PleasePrintAll Information / . <br /> Pnaper+ xanie P✓ 0507-151-9685-9 <br /> yon 8 Danielle Kools <br /> Property Owner's Mailing Address Property Location <br /> 8318 Flagstone Drive Govt.Lea <br /> City,Sme VPC Phone Number ,/SE II NE L,Seaim, 15 <br /> Madison,WI 9 (cac)t0ne) <br /> T 5 N; R 7 EorW <br /> Ii.Type of Building(cheek all that apply / Let d� <br /> laIoraFackyDwelling-Reutherof 3 1 Subdivision Nom <br /> • Block a . <br /> o Publie/Cmmtaeml-Descalse use 0 City or <br /> o Style Owned-Denote U CSM Rumba., 0villugeor <br /> Gm <br /> ✓7655 ®Tovaof Primrose <br /> III.Type of Permit: (Cheek only one has on line A.Complete Irma B if appReable) <br /> 't-Zit New System 0 Replacement Sysian ❑Trerementhholdng Tank Replaeemem Only 0 Other Mod)rmlion to Existing System(eapien) <br /> B. ❑Permit Renewal 0 Permit Revision ❑Osage of Phnmber ❑Permit Transfer to New List Previous Pored Number and Dole baud <br /> Before aphelia. Owner <br /> IV.Type of POINTS System/Component/Deviem(Cheek all tint apply) <br /> 0 Non-Pressurized la-Ground 0 Ptemnriad la-Ground eit M-Grade ❑Mound>24 is of suitable soil 0 Mound<24 in.of suitable soil. <br /> 0 HoldunmTeak 0 Other Disperse!Component(explain) 0 Pretreatment Device(explain) <br /> V.DLspertalfTreatmentArea Information: <br /> Dmiir'Flow(gpd) Design Soil Application nmetgpdsl) Disposal Area Required(sl) ' Dispersal Arta Proposal(si) System Elovdion <br /> C/450 0.6 750 750 112.7' <br /> VI.Tank info Goaesym Total f of Manufacturer Gallons Mils Manufacturer a <br /> R <br /> y �° <br /> lien Teaks Entraps Tanks a. 3 3 I 3.1 8 <br /> U m m CO E d <br /> &SenecasHataa,e Trek 700/550 1250. 1 Crest x . <br /> ViL Responsibility Statement-1,the underslped,sera -..ndWRty far installation of she PO'tVTS shown on the minded plans. <br /> Plumber's None(Print) Plumber.t tare MP/MPRS Number Business Phone Number <br /> f4LL' 1.1 _4... I 'J /ag2O,Z c - viv <br /> Plumber's Address(Street,City.Sled,Zit Code) - <br /> /U7�t'o9 (M-9 &4' '? 1-✓i •a _. _ <br /> VIU.Conn. •artment Use Only ■1110" <br /> 1�: •• d 0 Disapproved Permits Fee _ Date Laved (p� ' ��'� <br /> 0 owner Given Reason for Denial I,b4-.14(4)' . 2 1-4 �",,„,_� �\ <br /> LC.Conditions of Approvol/Rensons for Disapproval MI. <br /> (- 10-6.4-r-r-7 A--r-(z.r-A„\F____ ........... <br /> • <br /> Attach to complete pions for the system and submit to the Comic only on paper Sol tar than r iL's I l Inches le rise <br /> 550-6395(R I I/11) <br /> it <br />