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U <br /> Safety and Buildings Division County / <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> isconsin Madison,Wl 53707—7162 Sanity Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 �p C T� <br /> Sanitary Permit Application Sete Plan l.D Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide �2 <br /> maybe used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name ♦ Parcel# Lot#L/ Block# <br /> S 17 o Y 00 .2 V/ a 6o0 <br /> Property Owner's Mailing Address Property Location Ar—/G 4—2 <br /> z /;;,0/ 3J `/., %, Section / 6 <br /> City,State fip Code Phone Number <br /> r <br /> ..,( li o one <br /> II.Type of Building(check all that apply) --f7 T 3�N; R�/ E o(�V <br /> X+or 2 Family Dwelling—Number of Bedrooms __ a._.'- ame CSM Number <br /> ❑Public/Commercial—Describe Use 7e _ <br /> ❑State Owned—Describe Use r/ ❑City_❑vi age,ISTowrlship of <br /> w e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑New System y Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permi[Renewal [I Permit Revision [I 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 7kMound>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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 304 / 50 6) Sod 9?, y <br /> Vl.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> NewExisting <br /> Tanks Talcs <br /> Septic or Holding Tank 75- 7S-0 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS/shown on the attached plans. <br /> Plumber's Name(PrintL Plumber's Signature MP/MPRS Number Business Phone Number <br /> zz7� 3Y5-7z�G <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Vill.Coun /De artment Use On[ <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issd g gent Signor NO Stamps) <br /> Surcharge Pee) <br /> ❑ Owner Given Reason for Denial ^CT r <br /> IX.Conditions of Approval/Reasons for Disapproval ` <br /> Aaach complete plans(to the County only)for the system an paper not las Man RIR x 11 inches in site <br /> SBD-6398 (R. 01/03) <br />