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Safety std Buildings Division Courcy//jj <br /> ` 201 W.Washington Ave.,P.O.Box 7162 <br /> isconsin Madison, WI 53707-7162 Sanitary Permit Number <br /> /(m be filled in by Co.) <br /> De artment Df Commerce (608)266-3151 IJ05;Z✓tp <br /> Sanitary Permit Application Son, Plan I.D.Number <br /> In accoM wit Conus 83.21,Vim Adm.Code,personal niformation you provide <br /> may be used for secondary purp.n Privacy Law,sl5,04(1)(m) Project Address(if different than mailing address) <br /> I. Application Nformetion-Please Print AH Infornmtiom (}� Dr, <br /> Property Owner'r Name parcel a /y B I'I l Lu x eloct s <br /> a,r��i S /NOS z9 63 Sev <br /> Property Owner's Ma iling Adhesa Properly Loeadon 0, i ¢3 <br /> S o5, Z <br /> City,Sun zip Code Phone Number — R' il,Scuion _ / <br /> q p 6DS�"aS -.3ag6 <br /> e (6 that J 3/ / 6 -O Z T t/n N: R /eFo f ) <br /> NII.�'Type of Building k all that apply) -F� <br /> pr or 2 Family Dwelling-Number mf Bedroums Suwivuty Name CSM Number <br /> ❑Public/Cummcrcial-Describe Use I <br /> ❑Satc Owred-Describe Use [Icily 11Vfllage DIT.Winhip of <br /> III.-Type e� <br /> ype of Permit: (Check only one box on line A. Complete line B if applicable) <br /> F <br /> Y vend Sysum ❑ Rluemem Sysum ❑ Trnmnem/Hoding Tank Relacemem ONy ❑ Odar Mwificuion m Fuisfing Systan❑ permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Dau Issued <br /> Before Expintiun Plumber Owna <br /> IV.Type of POWTS System: (Check all that apply) <br /> *Hon-Pressurued In-Ground ❑ MuuN > 24 iv.of suiable sod ❑ Motion < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sard Film, <br /> ❑ Co.tmcted Wetland ❑ Prcsm iced In-Ground ❑ Holding Tank ❑Penn Filter ❑ Aerobic Treatment Unit ❑Recirculating Saw Fit= <br /> ❑ Rairculit 5 nmetk Meda Film, EJ D.nchirilf Chamber ❑Drip Line ❑Gravel-len Pipe ❑Other(nplain) <br /> V.Dis reatmg!Area Information: <br /> Design Flow(gpd) Design Soil Awlicaten,Rare(wds0 Dispenal Arm Required(sty Dispersal Am Proposed(so Sysum Elevation <br /> s o f ?eo 9ov 19 : n <br /> VI.Tank Info Capuity in Tow Number Manufacturer Prefab Sim Suel Fiber Plastic <br /> Gallo. Gallo. of Unita COurreu Constructed Glass <br /> New F.aen, <br /> Nu T N <br /> Septic or NuWiry TaN <br /> Aerobir Tie.UNi J <br /> Daing CIusim, <br /> VII, Responsibility Smlement- I,the undersigned,assume responsibility for ImWlarion of the POWTS shown on the atlYhed pima. <br /> Number's Name(Priv t) Plumber i Sigm MP/MPRS Number Biomass Phone Numher <br /> e JPvz 7G9/ �Y9 7za 6 <br /> Plumber's Address(5trcn ,City,Sum,Zip Code) <br /> ,;It <br /> VI .Count /De at Use Onl <br /> Approved ❑ Disapproved Sanitary Perot Fee(include Groundwater Date Iuued banSiam a Sumps) <br /> Surcharge Fee) �'S0S7 .J,)t6� <br /> 11 Owner Given Reason(u Dural <br /> IX. conditional of Approval/Reasmu for Disapproval <br /> Absorb mmplen Plum(a rhe Loan,only)be the pm a on PaW tut Ind Won ala x 11 forams W car <br /> SBD-6398 (R. 01/03) <br />