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Safehjand Buildsra <br /> tDi W.Washington Ave r.0.Box 7101 <br /> �s�0nsi Madison,Wl 537077162 S.rotary Permit Nvmo¢r(rob Fllalan I,C;rJ <br /> Dopartment of Commerce fC .f z <br /> .� { St t F amaaci archer 1 <br /> S���i��uY F'e�°Ira�l� f;,���a��1r�19���� bl//J 1 '/ <br /> In aecordmlce with s.Comm 83.21(2),Wis.Adm.Code submission of this form to the appropriate governmental C/s/1WL V p r"r-VI'2L1) <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS arc Avject Addrass(if different than rnziling address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary qq pp <br /> uroses in accordance with the Piivacj Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print An Information <br /> Property Owner's Name Parcel H e <br /> Property Owner's Mailing Address Property Location <br /> at 3 07 %9rti A—C O', E. r <br /> City,State Zip Cade phone Number <br /> _5E yq 5f, %h, Section <br /> ,VJ��' f p l m lV 5;r-1,9 9 T 2 N; R /r(circle one). <br /> 11.Type of BuBding(check all that apply) Lot It <br /> ❑ l or 2 Family Dwelling-Number of Bedrooms OL Subdivision Name <br /> Block <br /> ❑Publie/Cro mercial-Describe Use <br /> —' ❑City of <br /> El State Owned-Describe Use CSbl Number ❑ Village of <br /> 19 Town of_ Jk&hco0 <br /> I IL Type of Permit: (Check only one box on line A. Complete ate B if applicable) _ tt,— <br /> A. .O.New System <br /> ❑Replacement System ❑ Treatment/Holding Tann Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. D Permit Renewal D Permit Revision D Change of Plumber D Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration O�ynur <br /> IV.T e of POWTS Sys tem/Com onent/Device: (Check all that apply) <br /> Non-Pressurized In-Ground D Pressurized In-Ground D Al-Gide D Mound>24 in,of..itable soil D Mound<24 in,oFsuitabl.soil <br /> D Holding Tank D Oliver Dispersal Component(explain) ❑Pretreatment Device(explain) __ <br /> V.Dis ersah7mahnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevat-2649 <br /> ion <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units <br /> e <br /> New Tanks Esusting Tanks ,2 v <br /> Septic m Holding TaN: 7577 7x0 <br /> Dosing Chamber .1!bd <br /> .5-4, <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> A?Ie, /7 ca /ca.s / / fit �olsYrs/ yitB�G vir> <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VII oun /De arttnent Use Ont <br /> Approved ElDisapproved Permit Fee Date Issued Issuing nature <br /> ❑ Owner Givrn Reason for Denial <br /> § J� Zoll <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plare far the system anal submit to the County only on paper int las than a 12 a 11 Inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />