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Safety ant Buildings Division <br /> 201 W. Coung//JJ <br /> Washington Ave.,P.O. Bax 7162 aL W/'w <br /> W isconsin Madison,WI 53707-7162 Sanitary Perm(Number no be filled in by Co.) <br /> De artment of Commerce (608)266-3151 49,,5'Zq1 <br /> Sanitary Permit Application Sun Plan I.D.Nomber <br /> In accord with comm 83.21,Wis.Adm.Cade,pars nal Nfornutuon Y.provide 0070 <br /> may be usW for secondary puryoses Privacy Uw,s15.04(l)(m) Project Address(if i iffena thin mailing address) <br /> 1. Application Information-Please Print AB Information <br /> PropeM Owmws's Na '�C Parcel M Lot 0 Block 8 <br /> c r1,0J5om oya 2s�2v az rod <br /> Property Owner's Ma iling Address Property Location <br /> City,Sul, / r �ip Cade P/hone Number -55—ay yNW y.5uoon pZt <br /> /' ,J 6G C.ay "Sy�'YD pSY"• T.30 N: R ��(B'V) <br /> �1sqq1.""Type of Buildin check all that apply) 3 <br /> error 2 Family Dwelling-Number of BMrooms Subdivision Name CSM Number <br /> 0 Public/Commercial-Describe Use <br /> 0 Sun Owueii-Describe Use OCity OVdlage owhship of <br /> GJ oo ae � <br /> III.Type of Permib (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New S stem <br /> y Repluemem System ❑TrommenUHOMing Tank Replacemea Only ❑ Other Modification not Existing System <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit Tramfer to New Lien Previous Permit Number and Dau Issued <br /> Before Expiration Plumber Owner <br /> N.Type of POWTS System: (Check all that apply) <br /> a�f <br /> 0 -0 Non-PressurixIn-0rm cal 0 Mount > 24 m.of suiuble sod K Mount < 24 in.of stumble soil 0 AtGrade 0 Single Pass Saud Filter <br /> 0 Constructed!Wetland 0 Pressuriad In-Grount 0 Bolding Tank ❑Peat Filter 0 Aerobic Treatment Unit ❑Recvculnting Saud Filter <br /> 0 Recirculating Synthetic Media Filter 0 Leaching Chamber 0 Drip Lire 0 Grovel-less Pipe 0 Other(explain) <br /> V. Dispersalffrealonent Area Information: <br /> Design Flow(end) Design Sail Application Ran(gpdso Dispersal Area Requved(sl) Dispersal Aro ProposM(s0 Sysnm Elevation <br /> VI.Took Info Capacity in Tool Number Manwfumrer Prefab Sim Snel Fiber Plastic <br /> Gallon Gist of Units Concrem Comwcted Glass <br /> Ncw Existing <br /> TaNs TaN <br /> Seaic a Boum T" ✓] <br /> Aerobia Tmmem Bili <br /> Dssim Osmnber O� C <br /> VII. Responsibility Statement- 1,the mdersignedr assume responsibmty w installation of the POINTS shown an the mmchhed plans. <br /> Plumbers Name rin t) Plumber's Sign rare MP/MPRS Number Buaivem Phom Number <br /> ZL4Le ,,.o ace/ 22>6�j 3Y9 7z�� <br /> Plumber's Address(Sum,City,Sun,Zip Code) <br /> �aX �� S'.i�e..� �✓ s � <br /> VIII.Counly/Departmimit Use Only <br /> AWrovd ❑ Duappmved SaNtary,Permit Fee(includes Groundwater Dan IssuM Issuing A Signa o Sumps) <br /> Surcharge Fee) 3000° �l <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reareas for Disapproval <br /> Attach compete pian on the Cumty ably)far the system on Paper oat ha mass gla x 111nrhn N she <br /> SBD-6398 (R. 01/03) <br />