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Safety and Buildings DivisionCounty <br /> 201 W.Washington Ave.,P.O.Box 7162 NAgr <br /> iseonsin Madison,WI 53707-7162 Sani ry Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 47 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy law,s I5.04(I)(m) P ect Addressif different than mailing address) <br /> 1. Application Information-Please Print AB Infor on I- - A �S <br /> d -# 9969/ A zr of .2 ACRES ow <br /> Property Owner's Name Parcel# Cot# Block# <br /> 5rk f►2EE <br /> Property Owner's Mailing Address Property Location -S) <br /> SS94 8+A Ck BIZOO� RD• y <br /> City,State Zip Cc& Phones Number Q —/. N��, Section <br /> 1N W► - 7�Q3 4 OIOO- 8 I+S (nim,eptte) <br /> TAN; R/6 EIW <br /> 11.Type of Building(check all that apply) <br /> -X,or 2 Family Dwelling-Number of Bedrooms S Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> 11 State Owned-Describe Use ❑City_❑Village fowaship ofjOAAgAtle <br /> III.Type of permit: (Check only one box on line A. Complete line B if applicable) <br /> A. *X�ew S tem ❑ Replacement System ys ep y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer in New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.NoT of POWTS System: Check all that apply) <br /> n-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑Single Pecs Send Fiber ❑ <br /> ConstructedWetland ❑ Pressurized in-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gmvel-less Pic ❑Other(explain) <br /> V.Dis ersd7reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Raw(gpds0 Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation <br /> 750 . 7 108o q4.0 <br /> V/.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 Tenks <br /> Septic mHot ding Took I 00 �, ( kW <br /> Aerobic Tsumsem Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plum. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> fcH�q /�onKiiJs 22SgSl IS &06 $1S1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 60 w 3s WE8 Wi S �� <br /> VIII.Couny./Department Use Oxily <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu' gent Si re(No Stamps) <br /> Surcharge Fee) /D ^ / <br /> ❑Owner Given Reason for Denial $l V 4pcL•G o4 <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Attach complete plias(to the County only)for the system on paper not leu than 812 x 11 Inches In size <br /> SBD-6398 (R. 01/03) <br />