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Dec, 21. 2009 9: O6Ah 11 r 1-1 0 . a _..W I. 1I No. 1867 P. 1 -' commerce.il. dv },Eery : � �'ilding3Division County Q C� ••-210PiliVds i t Ave.,P.O.Box 7162 Dane Dscan Madi ' 53707-7162 Sani[ r(t b fillp i b o.) • Department of C• mer rtt „HO-31111 MA ' San - -4'� B.1—' i r ?• r• .7 i , • t n Stara Transaction plumber In accordance with s.Comm.83.21(2),Wis.Adm,Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-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 purposes in accordance with the PrivacyLaw,s.15.04(1Xm),Slats. P �G HP C Application Information—Please Print All Information ! r Property Owner's Name ' Parcel II 'sere `ret-e ,rn rn L, t. C-,- a ' - I / /- , CIO 2 r Property Owner's Mailing Addre ss Property Location ocation q o0 O y e-ita O O/ t ei it e 3ovt.Lot City,State J Zip Code Phone Number /1-ir y,SP 'A, Section /V l.tl au�QGQ 1+4.1.1' 5I.// 1 (circle one) II.Type f Building(check all that apply) Lot# T q N; R1�B or W ❑1 or 2 Family Dwelling—Number of Bedrooms SubdivisipnName r Block# _ , Q �( /GYLo 3 PubIic/Comrncrc tat—Describe Use£ 1/Ch,10-mLS /{'eat El City of ❑State Owned—Describe Use CSM Number ❑Village of ITown of a U$ iv I HIT,. ertrft: ',. eck only one box on line A. Complete le) At Vtlew System 1❑Replacement System 0 T olding Tank ❑Other Modification to Existing System(explain) B• ❑',omit Renewal El Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV,Type of POWTS System/Component/Device: (Check all that apply) ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil 21 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) - V an eatment Area Information: e4irgn Flow( ) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) 1SystemPlcvaticn P "`- ^ �� '�VI.Tank o Capacity in Iota[ #of Manufacturer Gallons Gallons Units `� _ � U� o New-rinks LxisringTanks t, gu gt . i A arg u su r£5 a Saprif or}folding Tank 2^20 00 yea a — /21 et di e AC Dosing Chamber VII.R�IOnsi1111itSlatement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number kel nne f--h �pise,- )k-do, ///tsJ[ r ' o-A,/ 6,00- evf- �s>7 L Plum Address(Street,City,State,Zip Code) ']3(* i —Do,r (. \ 'IDr -t Qnie_ W. 53S VIII.County/Department Use Only Approved El Disapproved Permit Fee Date Issued Issui gent Si ❑Owner Given Reason for Denial .3 /n ,, - . ,lpf IX.Conditions of Approval/Rcasons for Disapproval 7 / echtil3 -- a77a 7 Attach to complete plans for the system and submit to the County only on paper not less than 8 IC z 11 Inches in sine X-530Cc1 SBD-6395(R.02/09)Valid thru 02/11