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Safety and Buildings Division county �It-. <br /> 201 W.Washington Ave.,P.O.Box 7162 m ti-A- <br /> ` isconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4 MLO 3 S <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal intomtation you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(1 xm) <br /> L Application Information-Please Print All Information / <br /> PtopertyOtvaer'sName 628-413t,- t7Z//O <br /> 5� 01Parcel# Lot# Block#eve LEi� <br /> Proparty Owner's Mailing Address Iq <br /> ''77�II Property Location <br /> 92-02 Me/5eT KcC. C.L. / <br /> City,State Zip Code Phone Number '/•, _`/., Section-&,2-- <br /> S � <br /> /-73 -86 T -N; R./_El <br /> PW ) <br /> Subdivision Name CSM Number <br /> ❑City ❑Village2Townshipof _ <br /> 'LL Type of Permit: (Check only one box on line A. Complete line B if applicable) e?75r�L i t L Rvoq <br /> A ❑New System <br /> Replacement System ❑ Treatment/Holding Tack Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Pemtit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System: (Check all that apply) <br /> 9 Nan-Pressurized lo-Orourd ❑ Mound>24 in of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-GTade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Itm"lating 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(gpdsf) Dispersal Arca Required(at) .Dispersal Area Proposed(sf) System Elevation <br /> 00 ' -7 SSS o0 9i.B` <br /> VL 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 or3l01gtk O A?SO / <br /> �5K�4�c7 X <br /> Aerobic Treatment Unit <br /> Dosing Chmnber <br /> Mau KnIti <br /> S a t- areapomd11I for imfallatlon of the POWTS shown on the attached plans. <br /> Si MP Number Business Phone Number <br /> N6228 COUNTY LINER aa�879 <br /> Plumber' Code <br /> 715-635-7482 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved SerY Permit Fee(includes.Gramdwater Date Issued Issu' Si (No Stamps) <br /> ❑Owner Given Reason for Denial S"charge Fee) �t�(/• O <br /> DC Conditions of Approval/Reasons for Disapproval <br /> 1 <br /> Attaeh cempkto phos(to the County only)for the ryotem on paper ant kN than 91f2111[oche in she <br />