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Safety and Buildings Division County <br /> 201 W.Washington Aye.,P.O.Box 7162 <br /> 111scons n Madison,W 16-315 53707-7162 Sanitary Pe}mitNumber 2�(to be filled in by Co.) <br /> Department of Commerce (608)2b6-3151 J�r� J Pli <br /> Sanitary Permit Application State Plan LD.Number QL <br /> In accord with Comm 53.21,Wis.Adm Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(lxm) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information <br /> Tr2,asur <br /> Property Owner's Name - Parcel# Lot# Block# <br /> Link ri-Ii2 MA11bbMw 24 <br /> '— <br /> Property Owner's Mailing Address Property Location QOV} "F I3 3 <br /> City,Slate Zip CWe Phone Number <br /> M Pl n Zg 61 4W-L410 T Ll/'�N. R�C o U le <br /> il ) <br /> 11.Type of Baung(check all that apply) �1 <br /> VL'or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use 1 l I <br /> ❑State Owned-Describe Use ❑City_❑Vilhtgewn 'p of <br /> zRiksNi <br /> 111.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> d1 <br /> A, .New System ❑Replacement System y ep y ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B• ❑ Permit Renewal i ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Tv e of POWTS Svstem: (Check all that a h) <br /> CS.a,Ya--Pn,suriLed In-Ground ❑ Mound >14 in of,W Whle soil ❑ Nlomal 24 inof suitable soil ❑ At-Citade ❑Single Pius Sand Filter ❑ <br /> Construcled Wetkmd ❑ hossurwd In-Ground ❑ I Iuldim,Tank ❑Pcm Filter ❑Aarobic Treatment Cnit ❑RocireulalhlQ Sand Piller ❑ <br /> Recirculating Synthetic blabs Filter ❑Leaching Chamher ❑Drip Line ❑(ir:nel-les,Pipe ❑Other(explain) <br /> V.DispersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Applisnion Ralclgp 1,0 Dkper,al Ara;Required(A) Dispersal At at Proposed(st) system Ele<alion <br /> --45p ---- -- ---T --(o%41-1.s- <br /> VI. <br /> Tank Info Capa ity in Total Numbu I �1enulu.mrcr } Prefab Site Steel £cher i Plastic <br /> Gallons Gallon, of Lmis i 1 Concrete Constructed Glos, <br /> Ncw L,n;!n_ <br /> Tock, Tanks <br /> i <br /> Septic or Holding Tank + ! <br /> Acruhic Treamwnt Cnit <br /> I <br /> Daring Chamber <br /> VII.Responsibility Statement- 1,the on ers ned,ass tfi•installation of the POWTS shown on the attached plans. <br /> Plumhar;N;nne IP"nIl P u SS nal Iv1P M11PR5 Number Business Phone Number <br /> QW-7 as Irj <br /> Plumber Addkess Istreet,City,State,Zip od ll <br /> J� <br /> VII .County/De artment Use Onlc <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date I.saaxl ISSLlil -am Signal o Stump,) <br /> Surcharge Fee) 4 ��/l 019 <br /> ❑Owner Given Reason for Denial V <br /> tX.Conditions of Approval/Reasons for Disapproval <br /> Dt'FIOLTOK) C+ (ftE 501L A65oyzeri J GEGLS -To A&lt s <br /> G�os6L y ow i�t C <br /> JUN1 6 2W4 <br /> Attach complete plans(to the County only)for the system on paper not less than 9112 s 11 iochcs BUR <br /> tE <br /> VIl1Y TT GO(tINTY ,. <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />