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4j,I.7 Vtl != 11 <br /> it , <br /> `l DEC 1 6 2008 1..,), ' <br /> l <br /> eommerce.wl.gov Safety and Buildings Di on County <br /> 'L <br /> t , °20.1 W,Mafhington A.ve.,t.O.Box 71$2 Dane <br /> ttisconsin ' odison,WI 53.7914162 Sanitary Permit Number(to be filled in by Co.) <br /> €�- <br /> Department of Conwneree <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different thanmailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15.04(1)(m),Stets. Coffeytown Road <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel Or <br /> T. R. Olson Construction(Tim Olson) 0711-174-9076-6 <br /> Property Owner's Mailing Address Property Location <br /> 2729 Coffeytown Road Govt Lot <br /> City,State Zip Code Phone Number SW v., SE y., Section 17 <br /> Cottage Grove,WI 53527 347-5900 (circle one) <br /> _ T 7 N; R 1 1 E or W <br /> IL Type of Building(check all that apply) Lot t/ <br /> ©t or2 FamilyDwetling-Number of Bedrooms 3 1 Subdivision Name <br /> Block if <br /> 0 Public/Commercial-Describe Use 0 City of <br /> CSM Number 0 Village of <br /> 0 State Owned-Describe Use <br /> 8032 El Town of Cottage Grove <br /> 'ype of Permit: (Ch..k only one box on line A. Complete line B If applicable) <br /> ®New System t Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 11111 I •: •enewal 0 Permit Revision 0 Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWYS System/Component/Device: (Check all that apply) <br /> Li:Non-Pressurized In-Ground 0 Pressurized in-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DispersavTreatment Area Information: — <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.4 1125 1200 Equiv. 99.0' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units t v c u <br /> '.= <br /> New Tanlu Existing Tanks 41 o y y �' "'d <br /> k U rn vi l=.C7 P. <br /> Septic Holding Tank 1000 1000 1 Crest x <br /> Dosing Climber 600 600 1 Crest x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 4 4) if-t, , c'do Lie(' b)c3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 680 s5ieeJ Re( fail 6 i.e. c t 53`133- <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> r <br /> Appro`ed 0 Disapprovm1 CO <br /> /� ''�� <br /> ❑Owner Given Reason for Denial $32 ^ 1'7 d� 40 fA _ <br /> LX.Conditions of Approval/Reasons for Disapproval - _-41141 ir <br /> Attach to complete plans nor the system sad submit to the County only on pupae not less than a in x I I Inches to size <br /> p8 - a+16& ci e-hk-- `iGg157L. <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> • <br />