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i_ 1,,,,,! DEC 1 6 2008 i 1.12), <br /> catorneroe.wl eov Safety at+d 130diogaDiv+ 'on Camay <br /> r rr ► �■ ! i6 iM is MopiA∎!4.1e0 o;t 7l Dane <br /> it ti\ t7fY ?'tiir337Q{ 7162 )Sic PerndtNnmbc(to . <br /> Sanitary Permit Application stn <br /> N ecstrtlensc midi s.Canon.1.3.21C1),Wis.Mm.Coda rrhmisaioa Odds!Mtn to the prate governmental <br /> snit is required S Commerce. permit Note:Appliatdoq Punts for elatemwned POWTS err, Project Adders;(if different thimailii`ultimo) <br /> Submitted to the Personal informetioh You Pnwik may be meri for aeormde7 <br /> k y A ea ewmde ce wNh drt Pdraer taw.e.13.O4(I Xt4 sloe. <br /> Application Informadoa-)?lease Print AR I.fotroatton� <br /> -fie,�m,e Preme <br /> Coffeytown Road <br /> T. R. Olson Construction Pavel�l <br /> (Tim Olson) <br /> 0711-174-9076-6 <br /> Property Owner'.Meiling Addttetee — Property tomato, <br /> 2729 Coffeytown Road <br /> City.Stale .Zip C aide Phone Number Govt.Lot <br /> Cottage Grove,WI 53527 347-5900 SW �vt' SE 't' won 17 <br /> owe one) <br /> I .Type of e.lding(check all that apply) Lot* <br /> �?N; R 11 Par W <br /> al I art Pgrroly Dwelling-Number af):tedroans 3 1 Subdivision Name <br /> Mock 0 <br /> Q PubllciConinereiai-Describe Use <br /> 0 City of — <br /> 0 Stan:Owned-Ueesdbe the CSM Number ❑VII I.Ae of <br /> 8032 U7'oweor Cottarge Grove <br /> I'r ofPermlb ( ' .k only axe box on Ilse A. Compilete line if f+f sprplIctble) <br /> IR New System a Replacement system 0•fratmdet/yoidinsTank Repberment Only 0 Other Modification to amino System(explain) <br /> ■ Q Termk Revielan ❑Chop of Plumber ❑pooh Dtnaihr to New Lit PMAMI Permit Number and Dees Issued <br /> Seim 6xpintion <br /> Owner <br /> IY.T e orpOWTS Systce.lCotnoo.pef/DtMeC (cbeelt ib.t ly) <br /> DtNea•Prairaiaed la-Grottnd ❑Pre4ttrimed In-Oreend Q At- mite 0 Mound>24 in.&;alit*soil 0 Momd c 24 in.of nimble sail <br /> ❑tickling Tank 0 Other Dispersal Con anent(expl*io) 0 Pretreatment Device(whim) <br /> V. teatlmeit Ardl bifolnmlaflon <br /> Desist Flow(ppd) beriga Soli Applindian Rai e(apde Uitpeesel Area Required(it) Diepewel/vo.Proposed(st) System Elevation <br /> 450 1125 <br /> 0.4 in Taal tof 1200 Equiv. 99.0' �^ <br /> VI.Tank Info Meritttheha*r <br /> Oaiitms <br /> Gallons Units 'OM u <br /> hkwTaab itats5eeTmti 1 en 1 tMj A <br /> knrsretTak 1000 w <br /> 1000 T Crest x <br /> ' trsPUnt6er 600 — 600 1 Crest x <br /> — <br /> VII.It .., ,nalbiil Statertiest-I,me widen,s+ easaetta re .. 1,pity for iistatiaHoa alike ROWS ehrwa en tike attacked <br /> P1t.nber'a Name(Print) Plmtber•.Signature MP/MPR$Pemba l3onnets PflbmNy giber <br /> Plumber's 41-..se I�• `" a !. d_,./ 1I09-3d681 9to ye4 PS.oa <br /> (Street.City,State.rep Code) <br /> 6 s• - Re( fa!/ '.finer' e4.21 3393'3" <br /> VllL Cone ■ , nines Use Ord <br /> KApproved ❑Disapproved permh Fee Date Ismail Issuing Agent Signature. OF <br /> S, /l A _ <br /> 0 Ownr Given Raison Par Dania) IA 17 b � <br /> IX.Conditions of AppravalURtasoee for Disapproval —�� <br /> � 'f <br /> / <br /> t .......eta„„.pt■... tae ryater...rn• m rae Cousty rob'ro paper net ter kW e m 1,I ledus ti ems —. .'� <br /> De ” -a/r0f, ct Che4 - qt clis ,k _ <br /> ✓ SAO-6395(R.01/07)Valid elms 0]fi9 <br /> • <br />