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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 ju r rJ'714- <br /> tseonsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (60g)266-3151 475 <br /> 7 Q le)e <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,s 15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information 7 es-el <br /> t-C4., <br /> 0. fit') S 7 TiAi s�,./Daktrai I j--' <br /> Property Owner's Name Parcel# Lot# Block# <br /> &err 7. /4 es 0. ck-let 30 -oat/ea <br /> Property Owner's Mailing Address Property Location <br /> 6/0 4'tSO/i Cr?"' <br /> City,State M Zip Code Phone Number �', /. Section 7 <br /> Ccorl e✓ e, A & S.?..f,//t (,/d- 'Pe - /}.9/ (circle one) <br /> II.Type of Building(check all that apply)l T 41/ N; R 4-1-E or5) <br /> 12/1 or 2 Family Dwelling-Number of Bedrooms ASubdivision Name CSM Number <br /> oc 0 Public/Commercial-Describe Use LIST I 1 1,f 1 1)t')e.(JJc(,(k'or 1-�,5 � ;1�0C. <br /> ❑State Owned-Describe Use ❑City_❑Village(Township of-f.qjS t' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System [4eplacement System 0 Treatment/Holding Tank Replacement Only- ❑Other Modification to Existing System <br /> B. 0 Permit Renewal ❑ Permit Revision IDChange 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 /> 1 1 ion-Pressurized In-Ground 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter 0 <br /> Constructed Wetland 0 Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter 0 Leaching Chamber 0 Drip Line ❑Gravel-less Pipe 0 Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 . 7 ya 9 9,1,4 9d. Y <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 gro0 8'QD 1 skyw <br /> ik <br /> Aerobic Treatment Unit ' <br /> Dosing Chamber - <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attacked plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 2/e-k /S/e .,. f /?.-c ..d/1/ 01 0#1'S 8 S-/ 7/5 6' , - //S"7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 01776e //IA, , 3s— rveilsy'e t-✓rs96r93' <br /> Viilr County/Department Use Only <br /> ®Approval I ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing t Sign o Stamps) <br /> Surcharge Fee) r/J /I Vt& <br /> I]owner Given Reason for Denial 40.251 <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than S1/2 x 11 inches In size <br /> SBD-6398 (R. 01/03) <br />