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Safety and Buildings Division County }� <br /> 201 W.Washington Ave.,P.O.Box 7162 JJuojr-rT <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266.3151 qg µo7 <br /> Sanitary Permit Application State PlanI.D.Numbe <br /> m <br /> In accord with Com83.21,Wis.Adm.Code,personal information you provide 13 4 c)2 4 g <br /> may be used for secondary purposes Privacy Law,at 5.04(1)(m) Project Cup Addr'ess(if different than mailing addreso <br /> 31 7 <br /> I. Application Information-Please Print All Information # 3(/ X8 5`/5 SN WC1A) kX i�D I <br /> Property Owner's Name Parcel# Lot# Block# <br /> RAV E2 KoW SKl 0ao-4314-07-svo <br /> PropertyOwner's Mailing Address Property Location <br /> . '3545 TT0NfJSon1 l,AK>: Rd a �/ <br /> City,State Zip Code Phone Number ' 1'Z�`Section /'f- <br /> (NE85TtS12- VVI 5q-8g3 7/5 A6� - 49/l Tgo ,,; R1(� or <br /> We) C>Q <br /> I,IS�.Type of Building(check all that apply) <br /> h91 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village❑Township of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑New Replacement System R S <br /> y ep System <br /> ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision 11 Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS Sy stem: Check all that a 1 <br /> ElNon-Pressurized In-Ground Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Welland ❑Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersallTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 1 .5 '450 er, Acer 450 5, Freew 98.50 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank ,'52P 750 15DD2. Sf(AySL, ' 1E5F� ✓ <br /> Aerobic Treatment Unit <br /> Dosing Cbamber O 1 GNAW ✓ <br /> VII.Responsibility Statement-G the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pllu r's Si atur MP/MPRS Number Business Phone Number <br /> D A. RUR5HO[M '7/ 1.22- 7971 7/5 349 W96 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2 '7OZ /./ND ROAD Po. & 6 .sly 518EAJ W1 54o,7z <br /> VIII.Coun /De artment Use Only <br /> VApproved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signature Stamps) <br /> Surcharge Fee) 7 q <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plane(to the County only)for the system on paper not less than 8 Vf x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />