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Safety and Buildings Division County <br /> 1ISCOnsin <br /> 201 W. Washington Ave., P.O. Box 7162Madison,�4"( 53707-7162 Sanitar Permit Number C (to be tilled in by Co.) <br /> Department of Commerce (608)266-3151 4 76 <br /> 0174 <br /> State Plan I.D. umber Sanitary Permit Appo <br /> In accord with Comm 83.21,Wis.Adm.Code,personal in fo-rrtintfrfrOdirep, coo <br /> may be used for secondary purposes Privacy Law,s 15.04(I p in) SCAN <br /> NQtti+k'et Address(if different than mailing address) p 1 <br /> I. Application Information-Please Print All Information //ll oC,' <br /> �ea0 Lone el-„e Rai. ariAt <br /> Property Owner's Name Parcel a <br /> Lot x Block 4 <br /> vk Dau�5 da.o €3aq oa >oo <br /> Proper Owner's Mailing Address Property Location <br /> P,e. ,6oI s82 p y Gov . ccrr a <br /> City.State ZipCode y,.. . ., Section 2 / <br /> /t / / q^ /� 2 /Phone Number p� <br /> NJe�O�✓Ter k+-31 5+'8s > 17/5) -G✓j-3 (circle ; <br /> II.Type of Building(check all that apply) I ��N; R �6 E of <br /> I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> 0 Public.'Commercial-Describe Use <br /> 0 State Owned-Describe Use ❑City_❑Village fa Township of Oq klGNal <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y' 0 Replacement System 0 Treatment,Holding Tank Replacement Only 0 Other Modification to Existing System <br /> B. ❑ Permit Renewal 0 Permit Revision 0 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 /> 11 Non-Pressurized In-Ground 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil 0 At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland 0 Pressurized In-Ground 0 Holding Tank 0 Peat Filter 0 Aerobic Treatment Unit 0 Recirculating Sand Filter 0 <br /> Recirculating Synthetic Media Filter 0 Leaching Chamber 0 Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(Si) Dispersal Area Proposed Is)) S stet lev ton - <br /> b <br /> y50 ' 7 t�Y3 6� ebi . Iz.o <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Units ConcretePlastic <br /> Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /�M � <br /> r/W JOD� / <br /> Aerobic Treatment Unit <br /> t <br /> Dosing Chamber <br /> %II.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI ber's Name(Print) Plu is Signature MP MPRS Number Business Phone Number <br /> Plumber's Address Street,City,State,Zip Code) <br /> VIII,.County/Department Use Only <br /> Approved 0 Disapproved Sanitary Permit Fee/p(includes Groundwater D e s i u.ng. ignatur Stamps) <br /> Surcharge Fee) a¢ p(n�O <br /> 0 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval 1 <br /> 1 a4PR 2 0 <br /> 2004 i <br /> IING <br /> Attach complete plans(to the County oaf))for the system on paper not less than 81/2 x II inches in size <br /> SBD-6398 (R. 01/03) <br />