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` Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 !j/iA GPS <br /> isconsin Madison, WI 53707-7162 SamPermit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 qpj 3o7 <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 taw, sl5.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information (� <br /> .� -Danlel -7O <br /> Property Owner's Name Parcel N Lot M Block p <br /> KdrA4- I- oo(o-a41a-o3-oco <br /> Property Owner's Ma iling Address / / "� Property Locations <br /> 7a(] s Si �O W u,,` ",Section (7 <br /> City,State //�� l Zip Code Phone Number Y�-- <br /> Af e/.,.5 /J/�� 'S r�l Jrl 2o7 V/7 (circle one) <br /> IL Type of Buildin (check all that apply) T�1� N; RE 04n <br /> �K.l or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use <br /> ❑City ❑ illage o�"hi of <br /> I1I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I-Ww System ❑ Replacement System <br /> Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B. ❑ Permit Renewal El Permit Revision <br /> ❑ 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 /> (14n-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 ❑Peal 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 Ramigpdso Dispersal Area Required(sf) Dispersal Area Proposed(so System Elevation <br /> yso <br /> VI. Tank InfoCapacity 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 evo O 1,:, <br /> Aerobic Treatment Unit C/(! <br /> Dosing Chamber /On <br /> VII. Responsibility Statement- I,the undersigned,"some esponsibility for installation or the POWTS shown on the attached plans. <br /> Plumber's Name(Prin t) Plumber's Signa turMP/MPRS Number Business Phone Number <br /> Zid e- u �a - —, - Y 9 -;7-2f6' <br /> Plumber's Address(Street ,City,Stam,Zip Code) <br /> 120 k sir'-e/u <br /> VIIL County/Department Use Only <br /> Approved 11 Disapproved Sardtary Permit Fee(includes Groundwater Date Issued Issui t Signa o Stamps) <br /> Surcharge Fee) el X.D <br /> ❑ Owner Given Reason for Denial ,('I <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(b the County only)for the system on paper not Ins than 912 x l l inches in size <br /> SBD-6398 (R. 01/03) <br />