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\ 16 .j' L\...---- ------ \\_.' L)I., OLl I Z a.• SEP 2 5 2008 U) 4 11 corn erC .w't.goy afe and Buildings Division County D�NE F;tblic Heailh 9antonAve W. .,P.O.Box 7162 S C Ii , ., lmental a 'son,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) Department of Commerce 57 g iss Sanitary Permit Application State Transaction Number 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 Privacy Law,s. 15.04(1)(m),Stats. I. Application Information-Please Print All Information P operty Owner's NameCO Parcel# )f\IaRR V 4v0 0811-a g,7,-9G?o -3 Property Owner's Mailing Address Property Location 5G ./ 46 c 1'k T7 Govt.Lot City,State ,` Zip Code q Phone Number SE y. /, Section __ 'T�� /�.�-i 1 1 J5-�\,a 1 r'1(�, N; R 1 ,circ Gt one) IL Type of Building(check all that apply) Lot# __DS_ 1 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name Block# ❑Public/Commercial-Describe Use ❑City of CSM Number ❑ Village of- z ❑State Owned-Describe Use -- J� �Townof_ k CO `v 1, III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑New System ❑Replacement System XTreatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) List Previous Permit Number and Date Issued B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New Before Expiration Owner IV.Type of POWTS S stem/Com•onent/Device: Check all that a 1 1 ❑Non-Pressurized In-Ground ❑Pressuri n- round CI At-Grade CI Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil CI Tank ❑Other Dispersal Com n ❑Pretreatment Device(explain)t elain)V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation VI.Tank Info Capacity in Total #of Manufacturer I �j Gallons Gallons Units a V B . 8 T New Tanks Existing Tanks .0 c 8 - 1 fl 1 n 0 Septic d olding Tank 1 WO prL 4144 X. Dosing Chamber GOO VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Si wigs MP;MPRS Number Business Phone Number Plumber's Name(Print) r ZS 063 W !9 ^9O `N�NChQ�I �Rct� b ' 71 Plumber's Address(Street,City,State,Zip Code) .60 CAN Pc �, t i U..) .: VIII.County/Department Use Only Permit Fee Date .sued Issuing gent Signatur ■� KApproved ❑ Disapproved $ !�� j A '/I I- ❑Owner Given Reason for Denial O� t/v IX.Conditions of Approval/Reasons for Disapproval IN GRANTING THIS APP''OVAL, DANE COUNTY ENVIRONMENTAL HEALTH DOES NOT HOLD ITS LF LIABLE FOR ANY DEFECTS IN PLANS OR SPEC!'CA- TIONS, PLAN OMISSIONS, EXAM) : •► • - Attach to complete plans for the system and submit to the County only on paper not t .ahld 0 tIGIN8Td8tJ®TON OR ANY DAMAGE THAT MAY RESULT IN OR AFTER INSTALLATION AND RESERVE THE RIGHT TO ORDER CHANGES OR ADDITIONS SBD-6398(R.01/07)Valid thru 01/09 SHOULD CONDITIONS ARISE MAKING THIS NECESSARY.