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Jun. 29. 2009 3: 33PM.. No. 0836 P. 1 <br /> 200f4*i , .so,►M AY 1 5 LwLateti td uild.ices Division Count • <br /> s�+4,, 201 W.Ws.tt ti on Ave.,P.O.Box 7162 to <br /> L. _ r 7 wow_ -. - 53707-7162 Sanitary Porr)m/�/i]/t�Numberer(to •filled in by Co.) <br /> .. k fisc.o Do e 1�3nentof •Mmr•rR• ..1%'v 1-, .,• e,. �•■•. 1 I 14/ . <br /> y State Transaction Number <br /> t • eii ii Apps tiou <br /> In accordance with s.Comm.13.21(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 than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> pwpoees in accordance with the Privacy Lsw,a.15.04t1km),State. O ,544(1 g all r <br /> I. Application Information-Pleasc Print All Information <br /> Property Owner's Name Parcel# <br /> Ke& 4 Talc' F.�jG I• c\-. CAD 1"s„,4c5r i—/ V);r;IA;,jc ol. 01 "3-°1�l"5'pID-0' <br /> Property Owners Maiiin�Address fr Property Location <br /> SA5 " Lt. pr. _ Gavcl.ot <br /> City,State ll-- l Zip Code Phone Number 5 %, "Jo t', Section 0�9 <br /> r11.4. t? <br /> �• e-2 91 ) l 5357a 4431 7 5 3`1 T 1 N; R '1. 12)reW) <br /> TI.Type of Building(check ell that apply) �j Lot# <br /> ii 1 or 2 Family Dwelling-Number of Bedroom -3 a Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Ilse <br /> 0 City of .. <br /> 0 State Owned-Describe Use CSM Number 0 Tillage of <br /> t 01-1 GS$ 2 Town of mac.e` ;e.\d <br /> ILL Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A' g New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(=plain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Chsagc of Plumber 0 Permit Transfer to New I.ist Peevieus Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Deice: (Check all that apply) <br /> fiti Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade ❑Mound?24 is of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Bolding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Devise(eaeplain) <br /> V.D - rsaltTreatment Area Information: <br /> Design Flo}w�(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(If) Dispersal Area Proposed(at) System Elevation <br /> •5 V I y /lg.5 /JSQ !,.5Jio3.5/l 2.5 <br /> VL Tank Info Capacity In Total #of Manufacturer <br /> Gallons Gallons Units 1 1 A•8 .4 <br /> New Tenka Existing Tanks 9.M w 3 <br /> rn li C� <br /> lding Teak i 6 O fl 00 I ` Q X <br /> t b a err+ <br /> DeeMt elximber <br /> Via.Respomriebl;ity Statement-i,the undersigned,assume responsibility for installation of the PO'R'TS shown on the attached plans. <br /> • • Plumber's Name(Pint) Plumber's Signature_ MP/MFRS Number Business Phone Number <br /> Timothy J Jelle • . i, 227525 <br /> ,. 608-845-7466 <br /> Plumber's Address(Street,City,State,Zip Code) 1 d s <br /> 501 Commerce Parkway Verona wi 53593 Alt` <br /> VIIL Corm /De•artroent Use Only . �� • <br /> Approved 0 Disapproved Permit Fee Date -used Issuing 41140.6.W.Air <br /> 0 Owner Given Reason for Denial f��/ i �/ j -_ 116-1 <br /> DC Conditions of Approval/)Zeesons for Disapproval r�� �` ‘) <br /> t ; t\,S rj<ali (.sr_z,..64 `° 1 4 r 4.!0017,.. <br /> - Amrcb to complete plant for the sinew and submit to the County only oo paper not less thou 812 x 11 inches to site <br /> SBD-6398(R..01/07)Valid thru 01/09 <br /> .1)6f 11 14 C. y)i - /493D5 345.` <br />