Laserfiche WebLink
Jura 16. 2009 10:25AM ;,.....-..._ ,..'''' ..._-_--.. 7-71! ;,f• No. 0722 P. 1 <br /> i �'r.,, ,f I4 . <br /> j[1i,, JUN 8 2009 i f <br /> Comrnt .w1.0oV Safely any)Buitdings Division County <br /> ■ . ;;;r }i.. l y}!(v(>;s (ngton Ave, F.O.Box 7162 Dane <br /> CO I ;)vi;- ; {T;.:;1C;t ; M¢gion,WI 53707-7162 Srnitary Pelm�utNumbci+(�toixfrlledinby(bj <br /> bspottmbntar otnaneros 5203 <br /> Sanitary P rinit Application State Transaction Number <br /> In accordance with a.Comm.83,21(2).Wis.Adm.Code,submission of Ihb form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note;Appliance Comm for state-owned POWFS are .P....'1.—pet (if different lhanmaiiingaddraa) <br /> submittal to the Deputmeat or Cormterce. Personal information you provide may be used for aecondary <br /> _ sea in ec ortlance with t e Priv 14w a. s1mu, - Timber Lane <br /> I. Application Information-Please Print All Information <br /> Properly Oener'a Name •• Parcel# <br /> Mike&Cathy Gall 0708-183-9165-0 <br /> Property()marl Marling Address Property Location <br /> • <br /> 410 Bailey Drive <br /> °wit Tat•„. <br /> City,State I Zip Code Phone Nutrrber - SW Yee SW '4,Section 18 <br /> Madison,WI 53718 242-9442 (circle one) <br /> II.Type of Building(check all lltat apply) Lot N Y...7 N; R 8 _ Lor W <br /> (2 I or 2 Family Dwelling-Number of Bedrooms_ 4 2 (1/07 li)Subdlvition Warne - <br /> B. kN <br /> ❑Publ ideotnrnercial-DesscribelUse - - <br /> ❑City of <br /> USlateOwned-DesetibeWe CSMNumber El Village �� — <br /> 11885 63 Towor, Middletot) <br /> III.'type ofrertuitt (Check only one box on line A. Complete tine B If applicable) <br /> A. to New yyatem B Replacement System C7 Treatmentlliolding Tank Replacement only U Other Modification to Existing System(explain) <br /> B. Q Permit Renewal D Permit Revision ❑(lunge of Plumber ❑Permit Tranafer to New List Prenow <br /> Permit Number end Dace Issue) <br /> Berate Expiration Owner <br /> IV.Type ofPOWT8 System(Cornponeai/Deviee: (Check all th■t apply),_ t <br /> (.)Non-i'ressurizedIn-Ground CI Pitied Yn-Oroued ❑At-Grade 1-)t Mound 42d in.ofuuitablesoil ❑Mound<24 in.of suitable soli <br /> CI I1vlding Tank U Other Disperse)Component(captain) ❑Pretreatment Device(captain) <br /> V.DisITsel/Trealmeat Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsr) Di pee�rsal reaA Reyufed(at) Dispersal Area Proposed(sl) System Elevation -- <br /> 600 1,0 600 602 105.0' <br /> VI.Tank Info..� Capacity in Totes Nor- Manufacturer s <br /> Gallota Oullona Units <br /> New TRW ' Rektiartm s "" 3 <br /> A 1- 31° <br /> fler oldtenTeak 1250 1250 1 Crest x <br /> Doting Chunk( 750 - ` 750 - 1� Crest x <br /> VII.Responalbillly Slaletnmt-i,the undersigned,assume retpooslbllity for!kWh lion of the POW TS ahowo on the attached flint,, <br /> number)Name(Print) Plumbers Signature MMP/MPRS Number Busmess Phone Number <br /> 6ohert �veir"sey l r.e` ,�r, 2y6/// 411)gj --f -fi <br /> Plumbers Address(Street,City,State.Zip Code) - <br /> J5� ,r 6,i h G 9/Si /5‘i 0,-5, 0 G(/j ~ .s+3 S 7 <br /> VIf1.Counly/(iepartrmnt Use Only �(// <br /> pprored Q lAsepproted Permit Fee Vete Issued gent Signaler / <br /> (ry a / 1 <br /> ❑IhmasOlsen Ramon for Dental $ 0 8.p (p�a o ' i . . 'VIII <br /> IX.Conditions of Approval/Reasons for Dhapprorat <br /> Ans e to tompkie plea for the aytttem sad'abash to the Ceo■ty oaty on paper not btu than 5 10s t 1 loan to size <br /> 17k-- 2 3 <br /> /SBn•6398(R.01/07)Valid giro 01/09 <br /> - 49sa1 its -oo <br /> f)00 . 00 <br /> • <br /> 1 <br />