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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 KY y Q <br /> NVisconsin <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4-385+7 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy law,sI5.04(1)(m) Project Address(if different than mailing address)l <br /> I. Application Information—Please Print All Information _/t/ b <br /> Fax Ai e T• ce <br /> Property Owner's Name Parcel# Lot# Block# <br /> Diahe SSI/of'twran (,;,- 173 .5-&-2Cl2� <br /> Property Owner's Mailing Address Property Location f <br /> /7// /f6t it 74 Zn $49- y,, /✓W ,/, Section tJ <br /> City,State Zip Code Phone Number <br /> moi; OWfOn/re w..0 SY7s7 7�S- a3s-o�60 circle <br /> T N; R Eor <br /> II.Type of Building(check all that apply) P bt-47 <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Nam KA CSM`Nu/m11be//r <br /> ❑Public/Commercial-Describe Use a V-V, <br /> ❑State Owned-Describe Use ❑City_❑Village&Township of Ac./CSO n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that app I <br /> A Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3 00 . 7 40Pq q 130k %11S_ <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 b <br /> Septic or Holding Tank 8o Q D o0 1ea w <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P ber' Signal MP/MPRS Number Business Phone Number <br /> Rodrrc% /`/o //A s OLOX6 q/8' 7/S; 86ev- 44s`7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d 776o /V4 ,' We6s?4eo-- G1Jr s4�893 <br /> VI oun /De artmen Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin g Signatu o Stamps) <br /> Surcharge Fee) ",�D n O <br /> ❑ Owner Given Reason for Denial �f' �( <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> i <br /> J/ 400 2 ' <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 z 11 inches in size <br /> ZONINd UMy <br /> SBD-6398 (R. 01/03) <br />