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Safety and Buildings Division County he )re)s <br /> - -i <br /> `�� 201 W. Washington Ave0 P.O.Box 7162 (, r eonsin Madison,WI 53707—'/162 Sanitary Permit Number(to b ) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.Number -In accord with Comm 83.21,Wis.Adm.Code,personal information you provide may be used for secondary purposes Privacy Law,s15.04(l)(m) Project Ad ress(if different thss)1. Application Informstion-Please Print All Information <br /> Property Owner's Namecel# Lot#yUG3 —tSt� . 03 3 ,Property Owner's Mailing AddressProperty Location <br /> Ie ►►toe &�Y7-City,StateZi Code , /., Section <br /> P Phone Number <br /> SSn '0 S2. ( bb 8' -��-7 circle one) <br /> r[l.Type of Building(check all that apply) T J._.L N, R�E or W <br /> keR l or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> V <br /> UPublic/Commercial-Describe Use of q p �(,6j 14i-S <br /> -,State Owned-Describe Use <br /> ---- ---- <br /> []City []Village XTownslup ofJ114,Q <br /> rill.Type of Permit: (Check only one box on line A. Complete line B if applicable) — <br /> 7A. i New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ - <br /> _ P y Other Modification to Existing System <br /> B. I Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber <br /> Owner <br /> of POWTS S stem: Check all that a I _ <br /> IJ Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 inof suitable soil ❑ At-Grade ❑ Single Pass Sand Filter L_ <br /> Constructed Wetland ❑ Pressurized In-Ground Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recir^_u!ating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe <br /> V.Dis ersaVr1 reatment Area Information: Other(explain) <br /> Design FFlloow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation —� <br /> 7 �7 <br /> VI.7— ank InfoCa� Total Number _ <br /> Gallons Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons of Units j Constructed New Existing Concrete CGlass <br /> l- Tanks Tanks <br /> Septic o olding Tank y <br /> Aerobic Treatment Unit ' t e S-e Y' PC <br /> Dosing Chamber -. <br /> VII.Responsibility Statement-11,th <br /> Plu{n bar's Name(Print) e u ersigued,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI bar's Signet MP/MPRS Number <br /> / v e(S Business Phone Number <br /> ���'"`"'" c ser r� <br /> Lz f u �7C G- 860 ' � <br /> Plumber's Address(Street,Ci ,State,Zip Code) <br /> Irs d seer' <br /> VII .Coon /De artmenI Use Onl <br /> __T <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A igna a tam s <br /> Surcharge Fee) _ P ) <br /> ❑ Owner Given Reason for Denial <br /> X.Conditions of ApprovaVReasons for Disapproval V <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size _ — --- <br /> SBD-6398 (R. 01/03) <br />