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m Aug, 24. 2004 9: 35A u i No, 1194 F. 1 • commerce.w - AU 2 " NE.' Na-4-4 dings Division County Ol + Ave.,I?.O.Box7162 P/4rt- �"'� t Madison,W' 3707 7Tti2 Sani '" ' er • - '0' o.) Department ofCom =rce Pu•is Heailh MDC Sani �eriw m` pp ica ion state raa�tetiouNumHer • In accordance with a.Comm.83.21(2)Wis.Adm.Code,submission of this fbrnrtoThe appropriate governmental unit is required prior to obtaining a pantrary permit. Nam Application forms for state-owned POWTS are Project Address(If dlfibrent than mailing address) submitted to ibis Department of Commerce. Personal infarmatlon you provide may be used for secondary S cµLI,An C a ,R4:,purposes in accordance with the Privacy Law,s.I5.04(1Xm),Stats. I Application information-Please Print All Information Property Owner's Name Pared# 01 I S4 L 1, 091Q-061- 86 y5 - 0 - PropetyOwaeesMailing Address Property Location - W Prj a.L.v ( - • City,State Zip Coda Phone Number ,1,/E_ y., ll/�V', Section C. VV),Pt�stdLL. C.,,S S355'T G lr�C..�&1S3? T N; R 1? F. IL Type of Building(check fII that applyr` - \ t . • 3 2FamilyDwelling-NumberofBe 3 ) Subdivision Name Block# ❑Public/Commercial--Describe Use ❑City of ❑StateOwned-Describe tlas - CSM Number 0 Village of t to aPInwRof • .-OJJ i : III-Type of Permit: (Check only one box on line A. Complete line B if Applicable) A ©' stem ❑S Replacement stem Systems ep y -❑Treatment/Holding Tack Replacement Only ❑Other Modification to Existing System(explain) Pernik- ❑Pernik Renewal Q Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous.Permit Number and Date issued Before Expiration Owner IV Type ofPOWTS System/Con ponentlDevfce: (Check all that apply) .„____ ___ ©' --PreaeurizedIn-Ground ❑Pressurizedlu.Oround ❑At-Grade ❑Mound?24 in.ofauitablesoil ❑Mound<24 in.of suitable soil ❑}folding Tank [I Other Dispersal Component(erpI.ln) _ - ❑Pretreatment Device(explain) V.Dispersal/TreatmentArea Information: - Design Flow(gpd) Design Soil Application Rate(gpdsf. Dispersal Area Required(sf) Dispersal Area Proposed(of) System Elevation - 4t S-17 e, .A--/ 1I7rS— ii 2..Y 11.7' 473.E VL Tank Info Capacity in Total #of A4anut.taturer • Gallons Gallons Units Nee/Tanks Existing ta- s Saptt'a o 44,5a i-.4, if o a /b e~- ^ / DALMARAY X Dosing Chamber - -. - VIL Responsibility Statement-1,the widerdIgned,assume responsibility for installation of the POWTS shown on the r ttached plans. Plnmbtr's Name(Print) e MP Number Business Phone Number MICFIAELPACER Plum or's Signatur� � t.,.• 225.061 (60)555-3510 Plumber's Address(Street City,State.Zip Code) MARSHALLPLUMB NG,260 CANAL ROAD,MARSHALL,WI 53559 VIII Cotta /De.ailment Use I < Ailla Permit Fee Date I sued Issui. e•Approved ❑Diaapprovcd tea; ❑Owner Given Reason for Denial $ T S• /J r—,....- T X Conditions of Approval/Reasons for Disapproval - Div lila,ANIING THIS APPR AL, DANE COUNTY ENVIRONMENTAL HEALTH DOES NOT HOLD ITSELF • LIABLE FOR ANY DEFECTS IN PLANS OR SPECIFICA• TIONS, PLAN OMISSIONS, EXAMINATION OVER SIGHT, CO e, _ �� Attach to complete plans for the system and eubmtt to the County oety en pe ta PM/ A #iIE•• - MAY ��j THi RIGHT TO ORDECHANGES i OR ADDITIONS VES SBO-6395(R. UM)Valid 01/109 SHOULD CONDITIONS ARISE MAKING THIS K-- � 51`;3 tio NECESSARY.