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<br /> itcommeree..wLgov ("'S 1! Safety lad Build r s ivision 4o any
<br /> /+ Al W Mason A t 0.Box 7162 c
<br /> iii
<br /> V a n l�. .1' Madison,'NI . -7162 ? i tte/� fit fn by Cc.i
<br /> �oP✓iettrtent of Commerce 3
<br /> 1 I • • State Inanaa.ti Number
<br /> -, t ,,# .__--I
<br /> i° (r 4 8 Sese
<br /> In accordance with a.Comm 832)(2),W .Adrr.,Code,sub:riasian of this form to the spprrrrf ate gcvernmcntai •
<br /> unit is required prior to chaining a samta.y permit Note Application farms for state-owned POINTS are Project Addra,;(if different than maninga a `�
<br /> submlted to the Department of Commerce. Personal Information you prc•ide may be and for seconder/
<br /> plStoses in gecordaeee with the Privacy TAW,S.15.63('!)Sm}.Slits. f
<br /> I. A licati ;Information-Please print All Information
<br /> Property OwnerName �i psi 0
<br /> A` ke/L„_ r_,1 t dt.-cc 0 7 0 e - i/r a?oLoP?- t'�'Property Owner.Mal`nt;Address Property Location
<br /> J
<br /> (p 5- 4.3 —! i d Goa,Lot
<br /> City,
<br /> ( . • c Zip �� bone Number �S
<br /> Cc,,_ i c> A ,— t x.1.2 cQCi •ne)
<br /> TI. ype of Building(check all that apply) ' Lot e T 7 N; R W
<br /> laTor2 Family Dwelling-Number ofBedro• I 62 1 Subdivision Name
<br /> Block c'-"u MAo'fit/ , 3
<br /> ❑Public/Commercial-Describe Use
<br /> ❑City of
<br /> State Owned-Gescrit+e Us CSM Ni um er ❑Village of ,,fiIJn� J/
<br /> Town of 1 i 1 4 el/vtOhy
<br /> III,Type of Permit: (Check only one box on lane A. Complete line B if applicable) -
<br /> 1A•
<br /> 1.141-1<e'w System LJ Replacement System `Treettr.en.'Poiding Turk Replacement Only ❑Oder ModiSoation:o Existing System(explain)
<br /> R. (( ❑Pe mit Renewal Q I'e.-rrit Revision ❑'Change 3 P;umber 1 ❑Pemit.Trarsfer to New Iasi Previous Permit Number=crane e lsaue2
<br /> Before Expiration _J O• f
<br /> -IVV, 1Type of POWTS System/Component/Device: (Check all that ripply)
<br /> 0 Non-Przssurized In-Grocnd 0 Pressurized In-Ground ❑Al-Grade ❑Mound>:C;r..of suitable soil "Mound<24 In.of suitable soil
<br /> ❑Holding Talk ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain)
<br /> '—V.Dii. real/Treatment Area Information:
<br /> Ds.e1•••r cw ggpd)i Design Soil Ap;:ica".ion Rnte(gpdsf) ' Diapersa Area Req•ijired:et; - isperud Atari Prcooscd(sf) ' System Elevation
<br /> 1.Tank Info aciy in —I Tcta of i✓mtufsc�arrar
<br /> I
<br /> `'^ Gallons Gallons Units Si , rj g
<br /> New Tatilts Ertistias Tares
<br /> v j 4 � 8 Ar'I
<br /> Sono et?iehiQig�(icic a U w 1`d t —
<br /> d /6 Ida (
<br /> Dotingce«. ‘7 -, t�&v l r �
<br /> 1
<br /> VII.Responsibility Statement-I,the ttndcrslaned,testate responsibility for installat'Oa of the POWTS shown an the attached glans.
<br /> Plum 's Name(Priht) •t.mbpr .Si u 7 MP M15RS Number Busines;Phone Number
<br /> ' 11‹,d et■,.,F) 6-6 V ri- Or-n•A/Coj_...: 761Z,7 7
<br /> Pl 's Address(Srreet,City,State,Zip Code)
<br /> 7 3 Co L Tb t:9;- (` J r ► u e , k 31.K!e_ Lei X. ' 3 S"'e,), °( ,._--•-1
<br /> VIII.Ceunty/Departmeut Use Only
<br /> Approved ❑Disapproved
<br /> I ?milk Fes ' ' pDawIssuedd fie r�A;-tS attac Nov
<br /> —
<br /> 0 Owner ei von Reascr.for Denial I i go?L o J` 1 (� 'C*T//r(1�^
<br /> IX.Condition;of proval/Reasone for Disppproval
<br /> - S'E•Q' G✓''c1 ::},i:Y .r M f f' i'11-c-eM Ell r ig
<br /> 1- . i Rp A1/4..-7- /slOC ln(P J'1 r z,ti, -lc_ A-141- f'-vc Cvnea 7'
<br /> f � Y Mfr( ,.� 74,3v-----/-7
<br /> e.' (fit v i,�v 'ail AP''FQbF.L.DANE GOUNT�
<br /> r. r` �r 1LAt 1!f 005 P.:; r^ LF
<br /> �(,� ;arts to ctnnpkte plain for the system azd submit to the Cnuog•only on paper aoi less tp}A i,;t a 1,1 ank;ej j fa J7 1 lOtLl(;
<br /> bia— t •jl rIOhJS, �J:?,,nluV c^FACTS iii PIl1NS OR SPECIFIi�,•
<br /> e/�9,, �/ r�I C'Mt JruPJ3, EXAMINATION OVER-
<br /> i 1 T1— 5 1 "1�t SiG=?T,CtiiNSTi?U CN OR
<br /> SIGHT '?',i `'TI ` A .D)AMAGE THAT MAY
<br /> 'ri riFT:R ll'JSTAI-LATION AND RESERVEC
<br /> 5BD-6398(R.02/09)Valid thluO2/11 Tr 1''GHT FO 0 DEr�CHANGES OR ADDMONS
<br /> SHOULD CONDITIONS,ARTS,MAKiN3 THIS
<br /> NEC?SSAPY
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