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Safety and Buildings Division County <br /> F201 W. Washington Ave., P.O. Box 7162 / <br /> . iseonsin Madam WI 537M-7162 Sanitary Permit Number(m be filled in by Co.) <br /> Department of Co coerce 0)2663151 551 .2 / <br /> Sanitary Permit Application State Plan D. Number <br /> Uj <br /> In accord with Co m 83.21,Wis.Adm.Code,persoml informadat ym provide VW4 QeUI e�tl V' A1 <br /> may be used for secondary purposes Privacy Law,s15.0 (lxm) Project Address(if different than trading address) V v <br /> I. Application Information Please Print All Information <br /> Property, w ier's Name Parcel Y it Lot#Z/,�27j Block X <br /> s (/� <br /> !/ / N <br /> Property Owner's Ma iling Address Property Location p <br /> Al 17 r�S� u, u,Section I <br /> City State I . ' Zip Code/ Phone Number q <br /> �/-' 1 ✓ Z 7(�J ��O'Q fT /� (circle <br /> 1I.Type of Building(check hlI that apply) T 'f N; R i6 E orV <br /> IF 1 or 2 Family Dwelling-Numberl of Bedrooms � Subdivision Name CSM/Number <br /> ❑Public/Commercial-Describ#Use �Q1.56U'9 oyilhate �uutaaru eF Se(Jaw�(dKe <br /> ❑State Owned-Describe Use ❑City_❑Village vrowwhip of <br /> III. Type of Permit: (Check only one box on line A. Complete lice B if applicable) t 07-020-1. -f(,- 19 ' /S-3G0-043000 <br /> A' ❑ New System Replacement System ❑TremmenUHotdnrg Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑I Permit Revix m ❑ Charge of ❑Perm t Trawftt M New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S : (Check all that ) <br /> (Non-Pressurized In-Graced ❑ Mound > 24 in.of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> .LJI, <br /> Constructed Weiland ❑ 1f ressurtzed Int-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Medi Filter ❑Leaching Chamber ❑Drip Lire ❑Gravd-less Pipe ❑Other(explain) <br /> V. Dispersal/Treatment Ana Information: <br /> Design Flow(gpd) Design S oil Application Rate(gpdtf) Dispersal Area Required(sf) Dispersal Area Proposed(st) SF <br /> tem Flevatio <br /> VI.Tank Info Capacity in Total Nsm1mr Manufsnaer Prefab Site Steel Fiber Plastic <br /> G low Gallons of Unfits Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Bolding Tank ` <br /> Aerobic Treatment Unit <br /> Dosing Chamber 00 / <br /> VII.Responsibility Staten t- 1,the rmlessigaed,assume responsibility far ladallidion of the POWTS shown on the attached plans. <br /> Plu is Name rin t) li 's Sign MP/MFRS Number Business Phone Number <br /> v 8✓�95% (���dSG Bolo <br /> Plumber's Address(Street ,Ci Sete,Zi ) <br /> Z7Zzoglyr, <br /> VI I. ounty/pTartmient se Only <br /> Approved ❑ Disapproved Sammy Permit Fee(includes Groundwater Da Lssued Issui Agent Signature(No Stamps) <br /> Surcharge Fee> s RilS-Cy 10 3s� I( fth, <br /> ❑ Owren Giv Reason for Denial <br /> IX. Conditions of Approeasonss for Disapproval <br /> Attach complete plias(w the Coady ady)for the splen a pnpa not les than 91/2 x 11 inches in sin <br /> SBD-6398 (R. 01/03) <br />