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Safety and Buildings Division County �p <br /> 201 W.Washington Ave.,P.O.Box 7162 �(;1^�/ <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> isconsin <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.Number �W�''�l <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide V <br /> may be used for secondary purposes Privacy Law,s15 04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information 3= n� <br /> Tc�l( i'Duv f� <br /> Property Owner's Name Parcel#/0 of# W Block# <br /> Property Owner's Mailing Address Property Location A c- <br /> 4-/ <br /> y G/Je- /m6 tee <br /> City,State/ 7;Zip�C/ode Phone Number Cy• , Section�C b �G�./� W Tr / J T -7 N; �gcole o e <br /> II.Type of Building(check all that apply) <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village ownship of <br /> Q /tJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �4w System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification[o 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 /> on-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 ersal/freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> sb " 5- 66 C? I6, / <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 I Tanks <br /> Septic or XeidiagZnk /SO <br /> Aerobic Treatment Unit !/ <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pr' t) Plumber's Signatur MP/MPRS Number Business Phone Number <br /> :Z-Z 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> D14Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui Y�PzSignatur tamps) <br /> Surcharge Fee) 4 o,5^"P 31 _lq O <br /> 11 Owner Given Reason for Denial �(,J A/I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 91/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />