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IV AZ I'RA, tbLbV 4 IUD UMcilleyGUa i9l VVG!VV0 <br /> I;ni , ld r it ; ro:1 <br /> c,•. S tl <br /> t:ommercet.gov a ya ' :}tiltlings Division Ccumy <br /> i ,o JUN 2 a�iftk ' Ave..P.Q.Box 7162 Din& <br /> • ISCO If biid.�s`St'i t 53707-7tti2 Banda b r byCo.) <br /> t?eep77attrtrentatt` tmnarce. r: ,,,;rf, ,t- ( # � <br /> -1 . Stare Transaction Number <br /> Sanitary-- brit' '.CA-t- n <br /> In accordance wits.Comm.83.21(2),Wis.Aden Code,submission of iii.form to the appropriate governmental <br /> Wit i3 rcquirrai prior to obtpinieg a Netnhary punnit. Noec: Applies'en forme for eaito-owned POWTS an Prcjecr Address(f dilTereat iben nrsiting indI1ft ) <br /> submitted to the Department of Commerce. Personal information ,Ill provide nk4y be used for secondary <br /> purses in accordance with rho Privacy Law,a-15.04(1)(m),Scats. - Erb <br /> I. A pplication Information-Please Print All Information <br /> r Property Owner's Name Parcel ii <br /> PC,# A.f it v A aAA: _ O( C'7—2 G 2—900x.)-'C? <br /> Property Owner's Mailing -ddreas Property Location <br /> sD2 �iir r. lf(�, e(. Govt.Lot <br /> City,State �f Zip Code Phone Number 1i 1, VA. sctianr Xo <br /> (circle one) <br /> s{ ;a, r AZ. . —=Z.. T 63 N; R 7 13 or.441 <br /> LI.T}pe of Building(cheek all at iipply) J Ler# <br /> )i or2 Family Dwelling-Number o •-ntctrr3 .4 (DI !II .2 Subdivision Name <br /> ,Block r <br /> i <br /> 0 Public/Commercial—Describe U3o 0 City of r, <br /> D S isle Owned—De aribe Use CSh1 Number ❑ Village of <br /> i 4,07 Town ofd dire. <br /> III.Type of Permit: (Cheek only one box on line A. Compler_ line B if applicable) <br /> I A. INew Sysian ❑Replacement System ❑Trearmen'I-ioldirtit Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> T List Previous Permit Number and Dine Issued - I <br /> B. ❑Permit Renewal 0 Permit Revision ❑Changer"Plumber 0 Pennit Transfer e3 New <br /> • Before Expiration Owner - <br /> jY.Tv c of FQWTS S.stemrt/Cam.orient/Device: ..:.....iii ..,-- I <br /> C Noi-Pressurized In-Ground ❑Pressurized In-c id itizAD-G rilii Mound>24 in.of suitable soil ❑Mound a 24 in.of suitable soil <br /> C Holding Tank 0 Other Dispersal Component(explain, — 0 Pretreatment treannent Device(explain) <br /> ! VA Uis ersal;TreatmcntArea Information: • <br /> Des]go Flow(god) Design Soil Appli lion Ruute(gpdsl) Dispi. al Afe.t Required(al) Dispersal Area Proposed(sf) Systomn Elev■gionf <br /> Ce . !Q 1 I t • /;eelp !7•00 <br /> VI.Tank Info Capacity in Total #of Manufacntitir g� <br /> Gallons ''Ions Units dt V g °? <br /> New Tanks ! Existing Ttuiks o ° gt m <br /> wU in as w a-. <br /> Sepde asi eid:-�g Tpnk 1 2 t w r,E V <br /> Dosing Ch.unhe- &50 . -- - .,50 i I t•, <br /> VII. Responsibility Statement-1,the undersigned,assume rope -thinty the ti 5( H5tion of the POWTS shown on the attached plans. <br /> • Plumber's Name(Punt? Plumber's Signature °11■11 '-.11,41,VMPRS Number " Business Phone Number <br /> aeltew IJ, it-"t�.tk... LV- Z2bt6.5 °}3 t,--alQ3 <br /> Plumber's Address(Strcc5 CiT',Stare,Zip Code) . <br /> (r.01.' Clair. 14 INia-4,4-4,.. aa.c.i roll - <br /> VIII.Ce-nnl/D_epartment Von Only <br /> Appro led I ❑Disapproved -Pm-ra(yirFxe�r .i ' Dare Issu-. ,suin-AgenZ Si_ •ifirXi F <br /> I ❑Owner Given Reason for Doni,'it i (. V - 1- <br /> TX_Conditions of Approvai(Reasons for Disapproval <br /> • IN GRANTING -IS APPROVAL, DANE COUNTY, <br /> ENViRONMENTAi_HEALTH DOES NOT HOLD ITSELF <br /> LIABLE FORA .. _ :- -- <br /> Aflaclf f0 complete Onus for iki sy3wm and submit re the Cbuatr ody an paper not icss Olt p{t plc •IQNS,E)AMTh1ATION OVER-EICA <br /> DB—27 G$ ! SIGHT, CONSTRUCTION aR ANY DAMAGE THAT lNA'r <br /> t RESULT IN Of?><IFTER INSTALI_pTIONF AND FIESEHV'E� <br /> �.-.r i‹— 5a r I THE RIGHT TO OFIDER CHANGES QR ADDIITONS <br /> SEC ULD CONDITIONS ARISE AWAKING THIS <br /> SBD-6398(R.02/09)Valid dim 02111 NECESSARY. <br />