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Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 4YI <br /> �scons�n Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.Number <br /> �J <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide /�{ 4o2 Ar <br /> may be used for secondary purposes Privacy Law,a15.04(1 Xm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> at 78/-7 �" Oe Ws Lk rt <br /> PropertypOwner's Name Parcel w Lo[R Block# <br /> /ti B✓ ��deYson Od o Z/ 00t.6 <br /> Property 0 er's Mailing Address Property Location OV,+_, CDT. a` <br /> 753 Coe pr !rla� E <br /> City,State Zip Code Phone Number —%, Section 3 y <br /> { H b6Y a'rw✓C �Ii SS"O 76 (circlee®) <br /> II.Type of Building(check all that apply) ) T �{O N; Rl(ZE o <br /> ,WI or 2 Family Dwelling-Number of Bedrooms /Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use CJM V I D. 70 <br /> ❑State Owned-Describe Use ❑City_❑Village❑Township of 60fi�/4g, • <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ W News stem ,s,/ <br /> 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.T e of POWTS System: Check all that a 1 <br /> 11 <br /> ❑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.Dis ersaWrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sl) Dispersal Area Proposed(a; System Elevation <br /> 300 • 1? 300 336 ".X-6 <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 m Holding Tank <br /> Aerobic Treatment Unit <br /> Dosing Chamber se0 e�0(f <br /> VII.Responsibility Statement-I,the undenigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/ I Number Business Phone Number <br /> .4lb 7�5 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Court /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui gent Signa (No Smmps) <br /> Surcharge Fee) �y iy1� s <br /> El owner Given Reason for Denial ((P w t)♦1g �b <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach complete plum(to the County only)for the system on paper not lees than 8112 a 11 inches in nine <br /> SBD-6398 (R. 01/03) <br />