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Safety and Buildings Division County <br /> Visconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 v f N Madison,Wl 53707-7162 SanitaryPe it Number(to be filleJCo) <br /> (608)266-3151 94 eOSanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you providemay be used for secondary purposes Privacy Law,s15.04(1 xm) Project Address(if different than m <br /> I. Application Information-Please Print All Information .L-✓- �DZ6 �P� <br /> Property Owner's Name Parcel# Lot# Block# <br /> acrev &-e , ¢ 02 ad <br /> Property/Owner' Mailing Address Property Location• ' <br /> err %, yY, Section <br /> City,State Zip Code Phone Number <br /> VmAi ,r t 1v _ Ircle <br /> II.Type of Buildi (check all that apply) T N; RorU <br /> "YIor2Family Dwelling-Number ofBedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑village Xownship of VA <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> At- <br /> A ❑New System VReplacement System ❑Treatment/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.Type of POWTS System: Check all that apply)-_ <br /> VNon-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 crsallfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(s) Dispersal Area Proposed(at) System Elevation <br /> VI.Tank Info Capacity in dGallons <br /> Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> TanksTanks <br /> Septic or Holding Tank n/1AerobicTrcaorr tUnit <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 Print) P bar's Signal a MP/MPRS Number Business Phone Number <br /> Z <br /> s rQ. P- ,9093 3 7 s= 3 <br /> Plumber's Address Street,City,State,Zip Code) <br /> P'(O , B©y Baa uj-ed s <br /> VII Coun /Deartment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin ge ignature(N ps) <br /> Surcharge Fee) q <br /> El Owner Given Reason for Denial $Q?570 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x Il inches in size <br /> SBD-6398 (R. 01/03) <br />