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Safety and Buildings Division County <br /> Nvisconsin <br /> ar 201 W.Washington Ave.,P.O.Box 7162 ?u rn e�Madison,WI 53707-7162 SanitaPermit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 aa-7 <br /> Sanitary Permit Application State Plan I.D.Number ` <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide XJ <br /> maybe 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 <br /> o? d -7077 _5'w 4� <br /> Property Owner's Name Parcel# Lot# Block# <br /> /¢//eh / ,1,1,0 0 /d- N a-07 — 07/00 <br /> Property Owner's Mailing Address Property Location &\/,� LO� <br /> /9P 3 /6( G 7 AIE" -7 <br /> City,State Zip Code Phone Number V•. _'/ti Section <br /> 134& L M Al s s`3 e`1 7*_v—43 e/ -`%A Z 7T C�� N; R / Bcle Q110 <br /> II.Type of Building(check all that apply) <br /> X,or 2 Family Dwelling—Number of Bedrooms �' Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use Lala C <br /> 11 State Owned—Describe Use ❑City-0Village,4_5Townshipof Joc&toss <br /> III.Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> `k' ❑New SystemReplacement System ElTreatment/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 /> KNon—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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevati n <br /> 3 oG 5" � 40 00 <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 7S0 7.5`T1 <br /> Aerobic Treatment Unit 1 <br /> Dosing Chambcr Sop 1 1SOd <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 46nf all s_rS% S(6 —Gf/�`� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 0A 7;6a /u, 73- <br /> VIII.Conn /De artment Use Only <br /> ❑ Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu gent Sign (No Stamps) <br /> Surcharge Fee) r <br /> ❑Owner Given Reason for Denial �• � J—oa—0 <br /> IR.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 z 11 inches in sin <br /> SBD-6398 (R. 01/03) <br />