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Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 Rk r me 77' <br /> isconsin Madison,WI 53707—7162 Sanitary Perm itNumber(to be filled in by Co.) <br /> Department of Commerce (60g)266-3151 -/ 33 <br /> Sanitary Permit Application State 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,sl 5.04(l Hm) Project Address(if different than mailing address) ' t� <br /> 1. Application Information-Please Print All Information �E� hJ r^f 6,.n <br /> Property Owner's Name I Parcel# Lot# 73 Block# <br /> Saw, Mc C , Iloa mrd 9S So _ 08 300 <br /> Property Owner's Mailing Address Property Location <br /> ?) Z/ 7 /l a wg 1'e-14 R/4 r <br /> City,State Zip Code Phone Number —'/., Section /�f <br /> ereok/ n AAA le rt/ .5--r 1/-P (circle one) <br /> I[.Type of Building(check all that apply) T 10 N; R /6 E oro <br /> 'a I or 2 Family Dwelling-Number of Bedrooms .? Subdivision/Name C MtNum\berr <br /> ❑Public/Commercial-Describe Use <br /> El State Owned-Describe Use ❑City_❑Village Rrownshipof J6Ck'.0On <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �"NewS stem <br /> y El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> L�Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑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.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 41f . 7 (04/3 bye 90( . 9 <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 Tank COO X00 O <br /> Aerobic Treatment Unit <br /> Dosing Chamber beo bop <br /> VII.Responsibility Statement-1,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 /> Rle_/a Hki H s /.c.w� old�� f I 7/S-Q6G - 4/S 7 <br /> Plumber's Address Street,City,State,Zip Code) <br /> ✓` 7 7 6 O /S/w 3s- LV ed-s; "I-e, Wr- SH 89 3 <br /> V!2.County/Department Use On] <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Dale Issued Issuin t Signawr o Stamps) <br /> Surcharge Fee) l p� 1� r <br /> ❑Owner Given Reason for Denial � ",J�J a�f <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plass(to the County only)for tate system on paper not Ips trout 81/2 x 11 inches in sire <br /> SBD-6398 (R. 01/03) <br />