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07/20/2009 13:59 FAX 6088506848 Septic Specialists ) J002 q1j _'4.._. & L. U to t= , COmmerce.wll •,1 T Safety au.1 B ihriings Division County /� tn.L 1 V' opt��Ay��ashingto Ave.,P.O.Box 7162 On s e • 'scan Madiso�t}i 53707-7162 Sane u t I► d b o) . Department of C- era _ � 'Mic e• tnl • State Transaction Number Sanit• 'gars r° i '•avian In accordance with n,Comm.113.21(2),Ir1a •dm.Code,submission of the form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note. Application forms for state,-owned POWTS are Project Address(if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s 15.04(1)(m).Stets. t G I. Application Information—Please Print MI Information ^o H dt1 l Pw L1/'G le Property Owner's Name Parcel# ' r 1 11 o A_.`4,_ 'e.i • l - 61 - ;-(X. T"' r • Property 0 , .r't Mailing Address / ,.�� Ale Property Location /D n tt f e r C.n t l41� s la? � 1`` r le 4'Q. t/ Dr Gavt.Lot City,State Zip Code Phone • .Of ( Ai if 1/4 NE_ v.., Section 30 `Lee_ W, ,. i A (circle one) II.Type of Building(check all that apply) • rLot• T N; R �/ E or W RI or 2 Family Dwelling-Number of Bedroom 3 Subdivision Name •Block# �r�KDt'le4i PG/ k • ❑Public/Commercial-Describe Use ❑ City of ❑State Owned-Describe Use SM Number ❑ Village of 21 Town of art'54.01 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) A' ®.New System y ID Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) D. ❑Permit Renewal ❑Permit Revision E)Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV.Type of POWTS System/Component/ Device: (Check all that apply) KNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in of suitable soil ❑Mound<24 in,of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dispersal/I'reatment Area Information: Design Flow(gpd) Design Soil Application Rttte(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation 44so _ r 'l 11x5-_ 113 Y J ai,o qo.o 81.6 VI.Tank info Capacity in Total #of Manufacturer o Gallons Gallons Units _. 'E a ° °� u Now Tanks ' Eristing Tanks 1 V U 3 ic y h t v b i i+,0 a Septic or}folding Tank 1000 1000 I Moo/0.e_ I< , boring Chambar VII.Responsibility Statement- I,the undersigned,mistime responsibility for installation of the POWTS shown on the attached pines. Plumber's Name(Print) Plumber's Signature NIP/MFRS Number Business Phone Number k - Hn • MPi' -I' I/ . .'.Z V 08- f vFr• 6'73 Plumber's Address(Street,City,State,Zip Code) "13 C. l a r 1,'`\ r ■ u C k c( Al l.J. - .S 3 a t.). ` • VIII.County/Department Use Only _i� pcApproved ❑Disapproved Permit F j �D]ate sued Isauin gent Signs a?��❑Owner Given Reason for Denial $� `J' L /� t� �J/ IX.Conditions of Approval/Reasons for Disapproval IN G AP•.VA DANE COUNTY ENVIRONMENTAL NTING THIS HEAL H DOES NOT HOLD ITSELF LIABLE FOR ANY i)FFFCTStty 1'LANS 6RSYECIFICA. Attach to complete plans for the y tern aeu name'to this County any oa RNi<oiilgtR�y4A� (}SA#t s lnIA710N OVER- i - '1/_oaL, SIGHT. CONS f AUCTION OR ANY DAMAGE THAT MAY O�lii' RESULT IN OR AFTER INSTALLATION AND RESERVES �7 �- 5O 7 s4 THc'RIGHT FO ORDER CHANGES OR ADDITIONS SHOULD CONDITIONS ARISE MAKING THIS SBD-6398(R 02/09)Valid thru 02/11 NECESSARY. Y