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08/13/2009 09:01 FAX 2625604795 0Ma11eyEom 16002/003 r.Q IE C 1 ' •UG 12 2009 .f . . • it cott'rrne r• " .gov So ly a ', Buildings Division county 201 W. ashi ion Ave.,P.O,Box 7162 (�� ISCO - •IiC Health MDC Madiso.,Wl 53707-7162 S it 30.) Dopartrisant- „•:_r• u•nt- H - • , Sanitary Permit Application sta rarclion amber In accordance with s.Comm.57,21(2),Wis.Adm.Code,submission of This form to the appropriate governmental • unit is required prior to obtaining q sanitary permit Now Application forms for mate-owned POWTS era Project Address(if different lhanmellin address) submitted to the Department of Commerce. Personal information you provide may be used for secondary LD'+- U3 L t A Pt'cA �s�1 s ••acs in accordance with the Priva w .I .04 I m Slats. t 4` -f- o� I. A ilea ion Inforenalinn-PI sc Print All Information - P0. _/,.5 �‘Ct Prop. wncr' Namc + � ^ ` Parcel II . C'.("{ ►�1J, .3 o<<� ` ! a1\�kr 6/Zr010 -/83— er4..73-0 Properly Owner's Mar,✓Iin�Address . li rierty Location • Icoq+ t ro t Govt.Lot _Lk r Stale i Zip • Q Phone Number SW • 'e.IL) R Section 1 �ra(r1 e. .�J,_1_, ,1 ` ■ )3 f4-`.) °'(45 (air( one) , . • • T N; R 1Sor W II.Type of tattling(chock all that apply) (L( Let N �� • 1 or2 Fancily Dwelling-Number of Bedrooms Subdivision Name •• Block a �Ql\(�a Mai.hr , 0,c) etG •• ❑Public/Commercial-Describe Use ❑city of l..]Slate Owned-Describe Use �• _ CSM Number r ©Village of ( Town of • '(mil III. me•• sock only one box on line A. Complete line B if applicable) • 4 tiI New System ❑Replacement System ❑Trcatmenilllolding Tank Replacement Only ❑Other Modification to GrrWing System(explain)•0. • ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date issued Before Expiration Owner • 1V. ro of POWTS 5y stem!Comnanent/Device: (Check all that a X • • - Y. Non•Pressarixed In-Ground ❑Pressurized Inn-Ground ❑M-Grote ❑Mound?24 in.ofsuilabie soil ❑Mound c 24 in.of suitable soil ❑ Molding Tank ❑Other Dispersal Component(explain) _ ❑Pretreatment Device(explain) V.Dtspersal/I'reatntent Area information: - Design Flow(gpd) Design Soil Application Rate(gpds0) Dispersal Area Required(s[) Dispersal ArcaProposed(si) S al(,ktlevalion to VI.Tank-Info Cspaclty .of Manufacturer t o1+a . s t o le•S 1 t o S•$ Gallons Gallons Units a o u 0 New Tunis ---1 ,l, 1 flaming Tanks ' 1 1.1 'a 4 i in vi it t, 'A. 3eprievr l lerebgi d, la..3 (., la? : �� 'ram C amaber Cp��-'O _ _ .(0 5O 1 �� VII.It. onslbili Statement-I,the undersigned,assume responsibility for Installation bribe POWTS shown an the attached plans, PI ber's Name(Print) Plumber's Signature I'P/MPRS Number Business Phone Number (nc1 nil 2.- . ,. A- w , a RD 1 (DS 607-I31—I103 Plumber's Address(Street,City,Stale,Lip Code)— - Co$+3 K .. A _ 3-S . VIII.County/De arttnent a Ord • kpprovod ❑Disapproved Permit Fez _• �� ❑Owner Given Reason for Denial .3 'e ' '' '/ IX.Candidons of Apprevalrltcasons for Disapproval ' • NN GRANTING THIS AP-�.OVAL,DANE COUNTY • ENVIRONMENTAL H K H GOES NOT HOLD ITSELF LIABLE FOR ANY DEFECTS IN PLANS OR SPECIFICA, Ailed to compista plans for the system and submit Io the NAV only on p,pw s e e • i rYII . — . • .. • �13— .2t3 / • ' OR ANY DAMAGE THAT MAY RESULT IN OR AFTER INS1ALlATION AND RESERVE �i SBD-6398(R,01/07)Valid Ihlu 01/09 THE RIGHT TO ORDER CHANGES OR ADDMONS ' / ;/1L.K_ 5140% SHOULD CONDITIONS ARISE MAKING THIS (%�� NECESSARY • •