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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 L?(�r l g1/` <br /> Asconsin Madison,WI 53707- 1162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 472.2 23 <br /> Department of Commerce <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 8321,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,05.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Informal <br /> D(,(i?tom tt a r7/ <br /> Property Owner's Name Parcel# Lot# Block# <br /> Mict,A, ( o Lg-- 9eso of 'leo <br /> Property Owner's Mailing Address Property Location <br /> /t *S La rfC a'r Re//• y4, _'/4, Section <br /> City,State Zip Code Phone Number <br /> $ oorr s°v w -4 Re l lis- .sS"—JtS00 (circle�o{F) <br /> II.Type of Building(check all thatply) 7 �!Q N; R i4 E <br /> 91 or 2 Family Dwelling-Number of Bedrooms `{ Subdivision Name CSM Number <br /> ❑Public/Commereial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Villagc qITownship of .Sib � <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1rNew System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision 11 Change of El Permit Transfer to New <br /> List Previous Permit Number end Date Issued <br /> Before Expiration Plumber Owner <br /> rIV..T of POWTS System: Check all that apply) <br /> r{non-Pressurized In-Ground ❑ Mound>24 in.of suiu ble soil ❑ Mound<24 in.of suitable soil ❑At•Gmde ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑Preasurized In-Ground ❑Holding Tank ❑Peet Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersaLTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> /p00 `7 ps7 8G `f 9A 60q- 9d•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 Turk / <br /> yse /Aro Z- SG�i!✓ X <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(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ?Iak f/, E, J i� ot14 i.5-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 447-7bd // 3s we&-Yee � ti/1 Sef�73 <br /> VIII.CounV./Department Use Oat <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A S' hue(N <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Daniel I <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Mouth complete plum(to the County only)fair the system on paper not less than 8112 x 11 Inches in shun <br /> SBD-6398 (R. 01/03) <br />