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Safety and Buildings Division County <br /> Visconsin <br /> 0 201 W.Washington Ave.,P.O.Box 7162 (A e we t�- <br /> Madison,W1 53707-7162 Sanitary Permit Number(to be tilled in by Co.) <br /> Department of Commerce (608)266-3151 445&,7Z C� [ <br /> Sanitary Permit Application State Plan I.D.Number Jc�V1 <br /> In accord with Comm 83.2 1,W is.Adm.Code,personal information you provide '?35970 .7-) <br /> may be used for secondary purposes Privacy Law,s I5.04(1)(m) Project Address(if different than mailing address) (� <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel 0 Lot k Block# <br /> IY - ,k vL i,rs><en aao- q,?3S- 03 - X00 <br /> Property Owner's Mailing Address Property Location 60 <br /> / Jas- 3 Sr d /9✓t N. 3S" <br /> City,StateZip Cade Phone Number — • _'/4, Section <br /> wloar=ix S'`Y f/ 763 -S-S7-(0834 T fO (cocl= ) <br /> II.Type of Building(check all that apply) N; R !6 E or <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM <br /> CSM Number <br /> ❑Public/Comr <br /> U.mercial-Describe Use /3— oL 30 <br /> ❑State Owned-Describe Use ❑City_❑Village RITownship of 6,+Ie 14*14e <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> A New System ❑ Replacement System ❑ TreatmenvAolding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal rmit Revision Elrm <br /> Change of ❑Peit Transfer to New List Previous Permit Number and Date Issued <br /> ❑ Pe <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> 1: <br /> ❑Non-Pressurized In-Ground IR 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 ersalfTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> �fs0 Yso sc� �s <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New of <br /> Tanks Tanks <br /> Septic or Holding Tank /000 I <br /> Aerobic Treaunent Unit <br /> Dosing Chamber 600 �OO <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbei s Signature MP/MPRS Number Business Phone Number <br /> /?,eF He k;n s �tS�s/ 7�s 86y- 4's--7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760- W3�S (tJeE75�er wS s48yp <br /> VApprovcd7%0 <br /> artment Use Onl <br /> Disn roved Sanitary Permit Fee( eludes Groundwater Date Issued Issuin A ent Si aturcpp fr g gn (No Stamps) <br /> Surcharge Fee . � _/� � YL- <br /> Owner Given Reason for Denial OS--p(J l(M'•n <br /> IX.Conditions of ApprovaUteasons for Disapproval _ <br /> C;III� <br /> 2003 <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11incrd z1.1(V ptx/NG sV 7- <br /> I� <br /> SBD-6398 (R. 01/03) <br />