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I =s RECEIVED Safety Buikpngs Division County Dane <br /> • 201 W.Washington Ave..P.O.Box 7162 Sammy Permit Number(to be filled in by Co.) <br /> «+ :' . Madison,WI 53707-7162 <br /> � �� APR 0 5 /� <br /> DuD'icfWw Mnr I—S .20(`— 06076 <br /> ESaiiitersttftltilit Application State Transience'Number <br /> In accordance with SPS 383.21(2).Wis.Adm.Code,submission of this than to the appopeiate governmental unit <br /> is required prior to obtaining s sanitary permit Note Application forms the state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Sevin Personal information you provide may be used for secondmy <br /> purposes o.maxims with the Privacy Law,s.15.04(1 Xm),Seats. 2944 Hope Road <br /> L Application Infermties-Please Print A6 laformtlon <br /> aha s <br /> I----- 0711-301-8050-3 r''Nte MartSnyder <br /> Property Owner's Mairmg Address Property Location <br /> 320 Forreston Drive <br /> Govt C i t y,State Z i p Code Phone Number N E B NE <br /> Cottage Grove,WI 3527 (co�)30 <br /> 608 839-0392 T 7 N; R 11 E or W <br /> IL Type of Branding(check all that Lot 4 <br /> El Ior2 Family Dwelling-Nunberof 4 SubdivisimName <br /> / Block 2 Acre Metes&Bounds Parcel <br /> 0 Pub Describe-Describe Use /// 0 City of <br /> Cl State Owned- <br /> CSM Number 0 Village of <br /> Deseelre Use <br /> In Town of Cottage Grove <br /> M.Type of Permit (Check only one box on lire A. Complete Ilse B it applicable) <br /> A' 0 New System ®Replacement System 0 Treatment/HoldingTank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revistam 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number end Date issued <br /> Before Expiration a , <br /> IV.Type of POWTS Systm/Composent/Device: (Check all that ,7. ) <br /> 0 Non-Prastaired ln•Groud 0 Pressurized In-Grotmd 0 At 10 Mound>24 in.of suitable soil ourd<24 in of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment ' explain) <br /> V.Dkpenavfreatm_ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rase(gpdst) Dispersal t t - . Proposed NO System Elevation <br /> 600 JAI 0.(c •,.. 1 l ceo pato (/ 3 Sj 857.6' <br /> VI.Tank Info Capacity in Total S of Maau d <br /> oetra <br /> Gallons Galloon Units a Y fed$$ v <br /> New Tale &Seats Tutu C 8 j 9 <br /> a.0 H at iCO L <br /> SW& •Tk 1250 --- 1250 1 Crest x <br /> Doahg Chamber 750 --- 750 1 + Crest x <br /> VII.Responsibility Statement-1,the mdenfped,amine responsibility for Imh4tlsn of the POWTS shwa an the attacked phis. <br /> Plvetther's Name(Print), Plumber's Si Phone Number <br /> Nicer\ . cL (c1L _ A,VArAA . -ree"- G58Zl\c L.'oo-2cei-(1c,77 <br /> Plumber's Address(Street,City.Stale,Zip Code) <br /> I-/Li1S 61- r-e, / Z4'e-) l pie v t,t1Ot Li.1 . 1(Q <br /> Cousty/Departmnt Use Only <br /> ppnoved 0 Disapproved Permit Fee Date Issued _ .., <br /> 'P 0owne Given Rasonfor Denial s f2tt. —7 • t C �, <br /> Ix Conditlaes of ApprataVReasoass.Dbapproval( 7 D F4 (S FT htx,l.✓A/.fG 0 - r` <br /> % \ TEL Co/AP/K-771( ,JxL ef-ort/i 7k i 4 , vg-,t Cu/ P 1 <br /> r <br /> Attach es eospkee shim far the eyeless and a►att to the Cowley ssy es paper..e lea the.a>R sit lashes lads <br /> n ALA tif CIA, 51 1• Novi, <br /> SBD-6398(It.1 I/I l) <br /> I <br />