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16/24/2009 07:35 FAX 2625604795 J 0Ma11eyEom 1 001/002 * Ili jl -I _t;n II 1, II t:1 !E 11'11 _fl commerceAtiti!gov Safety d Buildings Division County 2EE Washidgti;ti Ave.,P.O.Box 7162 (ate, tiscontlairta Madis&r,'WI 53707-7162 Simile P tN er to be fit byCo-) purt ..,-i s + 'V ``Departmerrt of merss,� -- •-- S$ r - • w.� c a r tt State Transaction Number In accordance with a.Comm-8321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Nore; Application forms for ante-owned POWTS are Project Address(if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary puruses in accordance with the Privacy Law,s.15-04(1)(in),Stars. _ _ I. A •lice tionInformation-PleasePrintAlLInformation �IIVtV] � � Property Owner's Name Parcel# Dine A Crvi e, vet 081 I-324-32cx.,-2 • •Property Owner's Mailing Address Property Location 2_LI -Hairy L -1, Govt Lot City,State Zip Code Phone Number NJE 1/4 i, Section.32 kferCG4, IN I 53 3 TS N, R I (circle one) II.Type of Building(cheek all that apply) 4 Lot 4 V1 or 2 Family Dwelling-Number of Bedrooms .4. SubdivisionNaime Block d — ❑Public/Commercial-Describe Use ❑Ciry of CI state Owned-Describe Uso CSM Number Q Village of 450e, }Town of S tL f lig. _ III.Type of Permit: (Check only one box on line A. Complete lino B if applicable) A. i pNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) B. List Previous Perm it Number and Date Issued El Permit Renewal ❑Permit Revision Q Change of Plumber ❑Pepnit Transfer to New Before Expiration Owner TV.T e ofFOWTS S Stern/Con•oncnt/Device: Check all that a,,I 'N'on-Presvurizcd In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound a 24 in.of suitable soil ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.f is ersnllTrentment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdaf) Dispersal Area Required Of) 'Dispersal Aren Proposed(sf) System Elevation (.00O .4 1,5a0 1503 J . ' VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units a k o ,u aver,Tunics 'Existing Tanks '' u a a i ii a.U rn a us ail't7 FT. Septic er+ivid,g Teak I2,e6 - '" 12� s 1 ,+( GG TTJJ�� CL� Nt��,. ' Dosisib Cupsebor b50 (m50 I L- 4_ - VII.Responsibility Statement- t,the Undersigned,assume responsibility for installation of the POWTS shown on the manched plans. , 'Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number 11112(rev-)lnl • WO ko Pi. '— - .-- W, i. 2 2 t(25 8S I'810 3 Plumber's Address(Street,City,State,Zip Code) 611l 3 q1- V 1n.lauxaAece, WI 59.7 _ ___ VIII.County/Department Use Only I- I'drmitXee Dame Issued Issuing • enlSignal err A Approved 0 Disapproved 0 Oryuer Given Reason for Denial $ ��' a M __— - IX-Conditions of ApprovaVReasoua for Disapproval �+ ��,p t -,gT ZJ.. ik-L4 La > f ""'4 f" ��..- --_- �_ i 114 L11 -',iv t Irate riylS APPROVAL,DANE COUNTY I ±., M, • _ •• ' . . F `� Annah to complete ptaos for the system and submit ro the Cuunry only on payer nor�pta,ytu�t�'o 3 la �I �TS IN PLANS OR SPECIFICA- D T�IAOCINLS, PPLLAN/�OIIiv1ISSIONS,EXAMINATION OVER- C-11 --(5bOg/✓ SIGHT,CONSTRUCTION OR ANY DAMAGE THAT MAY RESULT IN OR AFTER INSTALLATION AND RESERVES SBD-6398(R.02/09)Valid dull 02/11 THZ RIGHT TO ORDER CHANGES OR ADDITIONS SHOULD CONDITIONS ARISE MAKING THIS NECESSARY.