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Dec. 21. 2009 9: 57AM1 irk �� 11 v 'ii No, 1$69 P. 1 <br /> commerce. .v fcty i r ildings Division County <br /> i� �. 0 21U)? ast i ( Ave.,P.O.Box 7162 Dane <br /> ISCO n - Madison, 4 53707-7162 Sani r(t(4 fill Ito.) <br /> a.) <br /> Qopartmollt of Go me r <br /> San Puhl".Health MR - <br /> San '+ t-,... i e State Transaction Number <br /> rn <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note; Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s-1S.04(lXm),Stets. <br /> I. Application Informat ion-PleasePrintAilInformation E/de r Lapie <br /> Property Owner's Name Parcel# <br /> 're et.e ; m an I-, L. C,. f • — I'41— , CO 2 r 0 <br /> Property Owner's Mailing Address n " Property Location <br /> •0U.se t a J o t'4 e LGi it e - Govt.Lot <br /> City,State tJ Zip Code Phone Number /4' <br /> JU� /., e5)� /., Section <br /> !.0 act ip[t.e_LL lox ..y 9 91 (circle one) <br /> H.Type f Building(check all that apply) Lot# r N' R�—B or W <br /> ❑1 or2Pamily Dwelling-Number ofBedrooms Subdivision Name <br /> Block s/ Li 31 Q 14 _de."3 <br /> ig Public/Commercial-Describe Use, e 1/Ch.'',s4-ma;. /{eir_i ❑City of <br /> El Stele Owned—Describe Use CSM Number Q Village of <br /> gf Town of 6 ri c illy I <br /> III.T -I 'erm ii-. eck only one bar on line A. Complete tom, p halo) <br /> 'f y' _ <br /> l'% ew System ❑Replacement System ;�I T aiding Tank ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Darn Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/CompoaenI/Device: (Check all that apply) _ . <br /> ❑Non-Pressurized In.Oround ❑Pressurized In-Ground 0 At-Grade ❑Mound>24 in.of suitable soil ❑Mound X24 in.of suitable soil <br /> 51 Holding Tank ❑Other Dispersal Component(explain) - ❑Pretreatment Device(explain) <br /> V ' •Mail r, reatment Arca Information: <br /> I. ign l_ <br /> Plow(g. ) Design Soil Application Rate(gpdsf) Dispersal Area Required CO) Dispersal Area Proposed(af) System Elevation <br /> 4 .----. <br /> '(VI.Tank , o Capacity in Total P of Manufacturer <br /> — Gallons Gallons Units h q v <br /> r <br /> NEW Talcs Existing Tanks d5 2 y ,n <br /> S gt rzo a, <br /> Septic or Holding Tank <br /> oi"-R-000 9dob p- ' led ('C <br /> Dosing Chamber <br /> ' - - <br /> VII.Responsibility Statement-I,the undersigned,assume restonaibitity for Ins(siltation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> nnp -f1 M'i'en )tt..o. ,4 i`e_.` .o 1Y_ 4t98- evy, e'l L <br /> Plum er's Address(Street,City,State,Zip Codo) <br /> 73(o l -DO)r (,'tti lj r i ue, bQAIe` Lan 5 1 d— <br /> VIII.Conn /De artment the On ' <br /> Permit Fee Date Issued Dssu in: <br /> Approved ❑Disapproved <br /> $ tares : 7 . <br /> +� _Milt► <br /> ❑Owner Given Reason for Denial • �� �y <br /> IX,Conditions of ApprovaffReasons for Disapproval - <br /> / <br /> D13 -7�a 7 Altach lo cvmpTeie plane for the system and submit to the County only on paper not lens chart 8 lit x 11 inches in size <br /> eQ).1 <br /> 'K-,5, Dog c G ! )9 c v , I Z/21 (0? <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />