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<br /> ul, 28. 2009 3; 05PM _ _, L E 11 V ( No. 1037 . P. 1
<br /> commerce.wi.!1,7
<br /> Snlbty and As Division County
<br /> 201 W.Washing(. 4.,P.O.Box 7162 is--,(�n/��
<br /> //m�,/� �+ [�� 8 ''lly Don, As Division
<br /> Sao i L co.)� Vons� 1 y
<br /> Department of Comm:roc
<br /> Sanita •y 1 t f'inlitt 1A-1 3.I : ion State Transaction Number'
<br /> In accordance with s.Comm.89.21(2),1 ',-,adm�maw, -r n.'l It i•to-iH pptnpriate governmental _
<br /> unit is requited prior to obtaining a sanitary permit. Note: Application forms for state-owned POWI•S arc Project Address(ifdif)crent 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,a.15.04(1)(m),Stats.
<br /> - ,� �- 3
<br /> 1. Application Information-Plcasc Print All information [A r ��
<br /> Property(wtter's Name - -_ ' -Parcel fl
<br /> r— �..._
<br /> ')C)....-. CA LA) 1i' 0 70b` a,3- v/0"i
<br /> Property Owner's Mailing Address Property Location
<br /> 9 69, I S/a y4
<br /> _ , 4J t _ _ Ciovt,t.pt
<br /> City,tita Zip Code Phone Number ,
<br /> r T 7 N; R fY eInr W
<br /> 11.Type of Building(check all that apply) lot tf
<br /> r2FamilyDwelling-NumberofBedrooms — Subdivision Name
<br /> G^ / - Block 6 1.4._ ! , .) —'eta_.._
<br /> n Public/Commercial-t)eseribe Use
<br /> ❑City of
<br /> U State Owned--DescribeUse , ,
<br /> CSM Number U Village of_
<br /> . 'Town of j�f i/e fv
<br /> 11i.Type of Permit: (Cheek only one box on line A. Complete line B if applicable)
<br /> A. ------
<br /> '4hTcw System U Replacement System U•I'reatment/Holding Tank Replacement Only El Other Modification to Heisting System(explain)
<br /> B. Cl Permit Renewal n Permit Revision 7 Change of Plumber U Permit'Iransfer to New
<br /> List Previous Permit Number and Date Issued
<br /> Before lixpiration Owner
<br /> 1V.Type of I'OWTS System/ComponentlUevieo: (Check all that apply) .
<br /> rNnn-Pressurized In-Ground U Pressurized Itt•Ground U At-tirade ❑Mood: 24 in.ofsuituble.soil C7 Mound<21 in,of suitable soil
<br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) ,_._- ,
<br /> V.Dis tersal/TrcatmentArea Information:
<br /> Design Flow(gad) Design Soil Application Rate(gpdsl) Dispersal Arca Required($1) Dispersal Area wposed(sf) System liievation
<br /> 0' 6, - / 'OO _ 9'ff, 3.5 9..5-r3 5—
<br /> vi.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units sa a Ali o
<br /> New'reap Existing Tanks g 0 ° -t 1 g 2
<br /> w t.) CO . u, 6:3 F,
<br /> septic or Holding Taal: ace �ad4, S /fez.Lt �'
<br /> � .ratN f�(
<br /> Dosing Chonbcr v e
<br /> 5-f
<br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the FOWLS shown on the attached plans. _
<br /> Plumber's Name(Print)(, ) PI{ 's Si r� MP/MFRS Number Business Phone
<br /> Number
<br /> U e i-k !' _ G r z P-T cl, ._ 'e ,e-- 41v"r -
<br /> PI er's Address(Street,City,State,Zip Code)
<br /> -7:3 G: t O)r (,`", r i vC b ct Ai e_ LJ 1. 3 .5-�- °(
<br /> VIII.County/Department Use Only
<br /> aApproved U Disapproved
<br /> Permit Fee� Date Issued Issam'• gent Signature y
<br /> ❑Owner Given Reason for Denial $l��J'•
<br /> 7-,Z7-49 � �` "�t
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> • . IN liANTINta THIS APPROVAL, DANE COUNTY
<br /> ENVIRONMENTAL HEAL.,,e, OI=S NOT E t�
<br /> --. LIAfIF t-). i i..0 ITSEI..tf
<br /> V a-1 o l AMA to complete prate for the and submit to the County only nn paper nn imilln 6�c,'t1 tdcr-.1t o(may iN GLA( S ofi pEcin CA
<br /> I N 011S7fUNS, ,k�1M1NATION()VER
<br /> C ! -r SI( f i i, �;n,V;;•li�i l�L tl V t�l?ANY f AmAGF Ti-iAT MAY
<br /> (j & -J 1 1 !0 RESULT IN OR Ar�TE_R INSTALLATION ANt�FEES Viwti
<br /> -111,7 RIO HI.I.TO ORDER CHANCES(-I A".'' sE
<br /> SBU-63911(R.02/09)Valid thou 02111 l-101.,J1l. t,Oj�()iTI{1il,ARISE MAKING i HIS +
<br /> NECf_,`,.,ARy,
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