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J.v.vt.. FAA ou000uu446 Septic Specialists I' g (ti it 11 Vl It @►oo� • 1D)1 1, ... commerce.v/ y Safety at I gdings Division County ______ . I A U G P 14u l ashi l�Ave.,P.O.Box 7162 /Ga n 'sCOn _ Madisctt;• I 53707-7162 Sat t e e edi o.) Department of Co mart= , Pub_s Htrtltl'rMsG s • }. State ransactlonNumber Salai 1 tI] . 1,Iii iAl 1.1 . In accordance with s.Comm.S3.21(2),Wis.Adm.Code,submission of this 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 I,aw a.15.04(1)(m) Slats p / I. A. lication Information-Please Print AB Information C 1t etr9t®le..t E exu n Propc Owner's Name Parcel# ,'r- , ! ).. ck.•Y -L;'cA . • d,as - l - ©oLt - a Prop Owner's Mailing Address Property Location 6 �.I�N. . c dr/ir'v�' `•aQ G. U);) o t J'(. Jt+Jkic ? Govt.Lot City,Stat Zip Code Phone Number , , J �� q N G /., 5� !., Section 3/ GS 4a IA— et T N; R (circle one) II.Type of Building(check all that apply Lot# 4'Tbr2 Family Dwelling-Number of Bedroom ^ 5-- Subdivision Name '' -/ Block# r t Oa ti t L t — ❑Public./Commercial-Describe Use —'- ❑City of ❑State Owned-Describe Use CSM Number ❑Village of g Town of cr.,r+CP &v 1 C III.Type of Permit: (Check only one box on line A. Complete line B If applicable) A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision El Change of Plumber ❑Permit Transfer to Now List Previous Permit Number and Date Issued Before Expiration Owner IV.T ,c of POWTS 5 stem/Corn.onent/Device Check all that a,41 'Non-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/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Disp el Area Proposed(st) -System Elevation '7 CO i y It? _ l e R G QZ,o ,10.o 471,2.5 qa,s VI.Tank Info Capacity in Total It of Manufacturer Gallons Gallons Units t e b New Tanks Editing Teaks u Q, ( Septic o Holding Tank % a.L ti � en wt7 w � %.%/GSO LC-5-0 1 /AleafiGe. a< Dosing Chamber VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number Ken fte•1-A+ /L1ei'e.- -/( 4 /17,,0_t,27, . .. • .2,2.`il•Y`f 6'08" F v9- d'77 j Plumber's Address(Street,City,State,Zip Code) 13i. 1 —00,r (,'N � rN0e baAi e_ LJ � S3 �t� `1. . vm.county/Departmcnt Use Only 1 . KApproved ❑Disapproved Permit Pee DIssued tas ' i;,- oU ,❑ Ow ner Given Reason for Denial $3l1 Y/ec //. ._.., ...Nrr IX.Conditions of Approval/Rcasons for Disapproval I IN GRANTING THI. APPROVAL, DANE COUNTY ENVIRONMENTA, HEALTH DOES NOT HOLD ITSE_F LIABLE FOR ANY DEFECTS IN PLANS OR SPECIFICA- TIO,�I P I.0ty NS,EXAMINA1 KVN UVEH- �� Attach to complete plans for the system and submit to the County only on paper not lgrtal �lj t( ;8gr,6 G— J�7i l tJ�V I ti ION OR ANY DAMAGE THAT MAY RESULT IN OFI AFTER INSTALLATION AND RESERVE Ch -- 5j "1'31L1 THE RIGHT TO ORDER CHANGES OR ADDITIONS SHOULD CONDITIONS ARISE MAKING THIS SBD-6398(R.02109)Valid thru 02/11 NECESSARY. •