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.Mar. 18. 2010 11 : 17AM - No. 2309 P. 1 <br /> SU ■ MAR 2 4 2009 L� <br /> was-and. Be <br /> bile rin 't r' ' biiion <br /> . WashiatglonAva,P.O.Box7162 Dane <br /> tit <br /> �• Cf_r C�t"!-= .- lseli iV1 53707-7162 Smimy Pamir N �[(m he filled in by CoJ <br /> D�ettmslfR d Cwmtsw 5/8 218 <br /> - Sanitary Permit Application State TraeactionNhhubve, <br /> In accordance with a.Comm.53.21(2).wit.Ad=Code.submissive of this No to the eppmpciete governmental PA/K 4/13 Lte L c <br /> unit is Required prior to obtaining i amino,pwmit. Note:Application toms for snits—owned POWTS me Neje=Address(if diffaentthanawilin5 address) <br /> . <br /> submitted to the Department of Comfier='Peraowl infomadon you provide may be used for secondary <br /> mower in accordance with the Privacy Law,a.13.04(1)(te),Stec. _— - Erb Road <br /> I. Applkatfoa Information-Please Print All Information ' <br /> Property Owner's Name Parcel* <br /> Nancy Hylbert 0607-262-8000-2 <br /> Frog Owner's Milling Address Property Location . <br /> 2809 Hollyhock Street Gave Lot <br /> City,State Zip Code PbooeNwaber NE v. NW %,section 28 <br /> Fitchburg,WI 53711 271-0956 T 6 Nc R 7 (circle a w) <br /> 1I.Type of Building(check all that apply) 0 Lot s% <br /> Q 1 or 2 Family Dwelling-Number of Bedrooms f `' / Subdiriaim None <br /> �/ Block p 40.2 Acre Parcel <br /> ❑Public/C.o®ncrcial-Describe Use 0 C+4'of <br /> ❑Sone Owned-Describe Use Number ❑Village of <br /> - [3 Town or Sfgi(1 ale <br /> . (ID.Type of Permit: (Check only one box ea)rite A. Complete Ilue tit if applicable) . <br /> A I New System ❑lteptao taent$y ❑TL vwNH{oldinaTmx Replacement Only ❑Other Modification to Exutias systan(explain) <br /> S. ❑P e r m i t Renewal ❑Permit Revision ❑C A t t t r g e of Plumber 0 Permit T r a n s f e r to New List Previom Permit Nienbu will Dam Ivuod <br /> Sefore Expiration Owner <br /> IV.Type of POVPTS Sritero/Covouent/Devlce jCheck all that apply) <br /> •©Noo•Piesseked bi.Ground ❑Pnaawittd In-aroma a ❑At•Grade 1 Mound a 24 in-ofauitable soil ❑Mound C 24 ie.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) _ 0 Precatrncn Device(explain) <br /> V. I/Tratment Area Information: <br /> F'low(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Aga Proposed(sf) Sysem Elevation <br /> 45� 1.0 450 456 100.0' _ <br /> to Total *or Manufacturer <br /> Vt Iank Info Gallons Gallas Units ,� ° — o i (1 NcwTmtb Exams Tank' 3 <br /> sepCeon:Milton Vak 1100 e---- 1100 1 Meade x , <br /> Chamber 600 1 600 1 Meade x <br /> VII.Responsibility Statement-I,the und_eralgoed,entree reeposability for histallatlea of the KNITS shown on the attached plant. <br /> Plhmbn'a lknnr(Print) P ....'e Sigaapue ° MPfiWRS Numbar &trip a Phone Number imoti <br /> Plumber', ddrese(Street.C(ty.Slide,Zip Code) r <br /> ,c 5 C.* ); \-\,, 1 k U,.r.,c,,. t ___ Li-it S € ' 7 <br /> �tyim paronetit Use Only <br /> 0 Dias vod Permit Fee os Dim lasted At r� <br /> 0 owner elven Reason for Denial <br /> $ �y � — _ <br /> IX.Conditions of Approval/Reaaerna for Disapproval <br /> -i SE f,96" DGjt /Zf t4(vrA>r 'tric-frie /4744/7/- <br /> • <br /> Attec%to mom pfae kw tee system P.O Mete to dee Cenwb en4 ere%per of tan than I tie x 11 lochs to IthAi <br /> SOD-6398(R.01/07)Valid the t 01109 <br /> t B - P'7(19(D <br /> ChK— JAI 5 b(61 <br />