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Safety and Buildings Division Com uniy <br /> 201 W Washington Ave.,P.O.Box'162 Qarn 'Qt I <br /> M <br /> ������� Madison,WI 53707-7162 Sanitary Permit Number(to be plied to by Co) <br /> (608)266-3151 <br /> Department of Commerce <br /> Sanitary Permit Application State Plan 1 D Number <br /> In accord with Comm 83 21,Wis.Adm.Code,personal information you provide 0 <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) ( 11 <br /> I. Application Information-Please Print All information �q$90 CvwNbtirrr LK A W <br /> Property Owner's Name Parcel# Lot# Block# <br /> koi2 P' FjtAe Y 03" S 335- 0 4400 <br /> Property Owner's Mailing Address Property Location G OV't-WT a— <br /> /01 fw //r►- St /t/ <br /> City,State Zip Code Phone Number ��', ��. Section 3s <br /> Sti A./C,s /✓/�. SS 3 �4 9S}-)33, S 3 (circle one) <br /> T �� N; Rs- �L E or® <br /> II.Type of Building(check all that apply) <br /> 6-1 or2Family Dwelling-Number ofBedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use Fty�Village FiTownship of Si✓Is✓ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System y WReplacwnent System ❑Treatment/Holding Tank Replacement Only L1 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 apply) <br /> )(Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable sod ❑ At-Grade ❑ Single Pass Sand Filter L <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/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> Ll 7 o _ <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 Tanke•- <br /> Aerobic Treatment Unit <br /> Dosing Clamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ?icA- //0,40 lef"5 ?-ccL, .Ofi� S`ffs r TiS- g66-";,/r7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -� 77,60 Nti 3, ' Webjrer, <br /> VII'1.Court /De artment Use Only <br /> 2 Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issum t Signatur tamps) <br /> p(� <br /> ❑Owner Given Reason for Denial Surcharge Fee) o <br /> (+� 77 7 J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in sin <br /> SBD-6398 (R. 01/03) <br />