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./....., r D IE b E II .'/ Ig -0 <br /> Check I'U 3 i' 'O b577-D .27t16.7,g <br /> commercemkg Safety ant 2u 4:ings Division County^ <br /> ■ ' APR 2221 i1 :.s.hirt i ve.,P.O.Box 7162 1. ek,�, . <br /> i sco n si i adisor, 13707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce S/7 76. I <br /> Sanitary Ub11C t3 State Transaction Number <br /> • ry I gyp' ication <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.15.04(1Xm),Stats. *. (0 0x-0, (�cl <br /> I. Application Information-Please Print All Information f�l x-1 <br /> Property Owner's Name Parcel# <br /> (-Y1 L)0, )03 .0 1 I I 4 9 6 -9r47D-0 <br /> Property Owner's Mailing Address Property Location _ <br /> 5(1`( Moh3'c..\\ v,eN Dr , Govt.L <br /> City,State Zip Zip Code Phone Number S' y� (1.":, 1/4, Section .�( <br /> t ` t��v SbN �! ' " 3 6g I (circle one) <br /> IL Type of Building(check all that apil• Lot# 1 T N' R ('�' r W <br /> fil 1 or 2 Family Dwelling-Number. ;. oms ...3 / 1 Subdivision Name — <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> crcrl a, K Town of CAA-Ai <br /> '� GY`Q2 <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. rm.,New System y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in_of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area R uired(sf) Dispersal Area Proposed(sf) System Elevation <br /> 45D ,y Ez.-flow cram ll2 5 (075 7• 0 W61%3 /q7.a <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u o $ o <br /> New Tanks Existing Tanks `'1 c o v h R r <br /> d <br /> CJ U h m A 1Z 5 C, <br /> Septic or Holding Tank i b Di, 1000- 1 Da, olv- \/ J� <br /> Dosing Chamber o Q - -.�s l 1 x <br /> VIL Responsibility Statement-I,the und- .'_ ed,assume responsibility for installation of ti POWT hown on the attached plans. <br /> Plumber's Name(Print) Plumber'. igna e I I•r'MMPRS Number Business Phone Number <br /> Timothy J Jelle IF .27525 608-R45-7466 <br /> Plumber's Address(Street,City.State,Zip C.. , <br /> 501 Commerce Parkway v - • <br /> VIII.County/Department Use Only <br /> roved ❑Disapproved Permit Fee Date Is ed ssu gent Signature <br /> ❑Owner Given Reason for Denial ----- ♦ax— f, <br /> IX.Conditions of Approval/Reasons for Disapproval r c. 9 / <br /> APR 2 4 2008 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 i 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> DANE COUNTY PLANING&DEVELOPMENT <br />