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Jun. 3. 2009 11 :05AM;Ht -- ._ No. 0629 P. 1
<br /> `- commercO.w• �p ty 00Iri. lldings Division County
<br /> ti i�t� JU� 2�1 WUWos111tt td�i1'Ave„P.O,Box 7162 6(15 0
<br /> 1 Madisin,Wi 53707-7162 Sanitary Permit Number(to be tilled i by Co.)
<br /> Dpa --- ; I0 L3 0 •
<br /> papattmeMott Corn l'ui. ••,e i k ' is i:,.j(`. _ ,. _. _
<br /> {� 'tt litt'•pi 'ea State Transaction Number
<br /> - i. tir�><�
<br /> Sariit
<br /> lu accordance with 5,(mum.a3.21.(2),Wis.Adm. C:uue,submission of ruts tan:tv the.•tpp;upriate go1einmental
<br /> unit is required prior to obtaining a sanitary permit. Note: Application forts for state-owned POWTS arc Project Address(ifdiffbrent than mailing address)
<br /> submitted to the Department of Commence. Personal information you provide may be used for secondary
<br /> purposes in accordance with the Privacy Law,s.t5.04(txm),Slats- _
<br /> 1. Application information-Please Print All Information
<br /> Property Owner's Name Parcel g .'
<br /> ,„ i\c4\. -( `]J L ---`-1:P\--I DV' (.4>ct Ve.'- `-k-- n k k 00
<br /> Property Owner's Mailing Address r - Property Location
<br /> Y.C,, �+-X*� 5 '1( (lovt.Lot ..._..._._
<br /> City,State Zip Code Phone Number h)E y,, o() '/,, Section fir'
<br /> ��/\ 'A ., boa-219 -0,-08 C� (circle one)
<br /> 1 Wcal�, 4.1� r �'" ICJ tom: :]t`j T O N; R I'Z_, (Opt W
<br /> U.Type of Building(check all that apply) • Lot II
<br /> Subdivision Name
<br /> r}1 ar 2 Family Dwelling-Number of tiedruorlis .. -. .
<br /> Block if
<br /> U Public/Commercial-Describe Ilse — 1.I City of
<br /> C:SM Number ❑ Village of 1�r�_ ......
<br /> U State Chvned-lkseribe Use 1l�1bwn of + `, �
<br /> _ 12614
<br /> III,Type9LkertnD
<br /> heck only one box on line A. Complete line B if applicable)
<br /> '; i ;��,r Syst ❑ Replacement System ❑Tte„abiient/Hnkling Tank Replacement Only n Other Ivfodilication to Existing System(explain)
<br /> _ ._.. List Previous Permit Number and Date Issued
<br /> R. ❑Permit Renewal n Permit Revision 1-1 Change of Plumber 1.1 Permit Transfer to New
<br /> Before Expiration Owner ..--1
<br /> __-.,-1417TypE S eft/C:oniponent/Devicet (Check all that apply) - --
<br /> \ , 1'aom-Presort rd In-Ground---ii'LJ' Pressurircd In-Ground U At-Grate ❑ Mound'24 in.of suitable soil ❑ Mound<24 in.of suitable soil
<br /> ❑ Holding Tank n Other Dispersal Component(explain)_ ,� ❑Pretreatment Device:(explain) vT_
<br /> V,Dispersal/Treatment Area lnforntntion: _ - -
<br /> Design Flow(gpd) Design Soil Application Rate(gpclst) Dispersal Area Required(sf) Dispersal Arca Proposed(sf) System Elevation
<br /> 750 I (IN 5 2..a s-0 Sl:,,`3 t 8.rs 1 %A°
<br /> VI.Tank Info Capacity in 'Total A of Manufacturer 8 4
<br /> Gallons Gallons Units E U 1 y
<br /> -2 I A g
<br /> Now 1':v,ks l:rialinY.I:o,1:.5 Q u. 10 `�'it V rir in w 5 a
<br /> ( krato.k otdinsTank /&So ` t✓4-"st (20Cti 16.41) . / ,–.
<br /> Dosing Chamber _ �
<br /> ti C O . _
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<br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) Plum 's Si_ tore Pg 1 p C. MP/MPRAb Number Business Phone Number
<br /> '�.� • �.A O(.'- 4. • . e/34 , Pl..l IVtEi J6- _.,'12:7'2 (1'`i 9 l2:0-41q-..16r5'
<br /> Plumber's Address(Street,City,Slate,Zip Code)
<br /> e)/i A14-1 cp 6 i`(-t( -L L)( La-h) t ..)0.-'[- u-2,c91\._s -t S a:-.5-9 Li- / 1
<br /> VITi.Connty1t)eI►arttnent Use Ong• AVM
<br /> tI Approved U Disapproved
<br /> Permit Fcc Date Issued Isstring • em Si�t,nn ��,/
<br /> r\ n owner Given Reason for Denial ,-,K� C. .I i „Mr_ ----
<br /> IX,Conditions of Approval/Reasons fbr Disapproval \
<br /> 1
<br /> . __.
<br /> A(sib to complete •es for the system and mbmit to the County only oe paper not leas than$in a 11 Inehs he stir
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