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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 &U/fl� <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co)of Commerce (608)266-3151 s4 p x-93 <br /> Sanitary Permit Application State Plan ID.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 19370&7 <br /> may be used for secondary purposes Privacy Law,s15.04(1 xm) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information ,, II <br /> 1120 Roberts Rd <br /> Property Owner's Name Parcel# Lt# Block# <br /> Marilyn Twining (29) <br /> Property Owner's Mailing Address Property Location Gov f. LV-T s- <br /> 1 Scarlet Hawthorn Ct. <br /> City,State Zip Code Phone Number Ya, Section 24 <br /> Woodridge IL 60517 630-971-0270 40 14(ciroleone> <br /> 11.Type of Building(check all that apply) T N; R r , <br /> I or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name CSM Number <br /> Public/Commercial-Describe Use t-��,,,, rr--lt__ <br /> ❑State Owned-Describe Use OCity ❑Village Gnownship of Scott <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable)0 7 Ooh-g-c1- -( ,- j (00S-0i160D <br /> A. ❑New System Q Replacement System y p y ❑Treatment/Holding Tank Replacement Only [I Other Modification to Existing System <br /> B. 11 Permit Renewal C1 Permit Revision 11 Change of ❑Permit Transfer to New <br /> 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 Q Mound>24 in.of suitable soil ❑ Mound<24 inof suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank Q Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line Q Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(grid) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sl) System Elevation <br /> 300 .7 96.33 <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 Tank 1000 1750 2 x <br /> Aerobic Treatment Unit <br /> Dosing Chamber 750 Weiser <br /> X <br /> VI 1.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pum is Signature MP/MPRS Number Business Phone Number <br /> Kelly Ferguson224069 715-635-2887 <br /> Plumber's Address(Street,City,State,Zip Cmde <br /> W9502 Dock Lake Rd Spooner WI 54801 <br /> Vll Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ge ignatur .[amps) <br /> Surcharge Fee)!,375�J 7- <br /> ❑Owner Given Reason for Denial Yy// // 8 Jae 2LV1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less Man xlp,x It inches in sin <br /> SBD-6398 (R. 01/03) <br />