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Safety and Buildings Division County <br /> V � //� <br /> M 201 W. Washington Ave., P.O. Box 7162 U cfvG� <br /> consin Madison,WI 53707-7162 Sanitary P Number(m be filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application Sade Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(1Xm) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information C) <br /> F <br /> Property Owner's Name Parcel A Block X <br /> D6 N t9ekrs0.J 01ZyZ/,33z" <br /> Property Owner's Ma iling Address! Property Location <br /> 07e/� Co ea(6-/ssY e A, 1A,Section_L— <br /> City,State L/� �/ rZi-p�Co�dSeeL Phone Number p <br /> /VOF_Ahmll1 /✓ 7 Jt�✓V 07�1-ZV I� vele ) <br /> II.Type of Building(check all that apply) <br /> T t N; R ell or <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivisiion' Name CSM Number <br /> ❑Public/Commercial-Describe Use U`Jr/' Zp <br /> ❑State Owned-Describe Use ❑City_❑village ❑Township of (W s4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) O _ <br /> A. ❑ New System y ng Replacement Only ❑ Other Modification m Existing System <br /> ys QReplacementS stem ❑ Treatment/Holding Tank <br /> B. El Permit Renewal El Permit Revision <br /> ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owren <br /> W.Type of POWTS System: (Check all that apply) <br /> XNon-Pressurized In-Ground ❑ Mound > 24 in.of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Welland ❑ 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 <br /> (gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3JVA • 7 41 <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 Teaks <br /> Septic or Holding Tank 7� <br /> Aerobic Treatment Unit 'V <br /> Dosing Chamber <br /> eco <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plamv. <br /> PI bet's Nam/e(Frio P 's Signa lure MP/MPRS Number Business Phone Number <br /> lumber's Address(Street ,City,State, Code) <br /> 2�2Zo 6'amr*oN a We cr <br /> -VIM.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu Agent Signamre(No Stamps) <br /> Surcharge Fee, 3 a5 oto 11-��-lo <br /> ❑ Owner Given Reason for Denial <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 812 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />