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Safety and Buildings Division County <br /> ` 201 W. Washington Ave., P.O. Box 7161 9 /l <br /> ►seons►n Madison, WI 5-315 - 7162 Sanitary Permit 2mber(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 'STA 8 [lea /TI' <br /> Sanitary Permit Application Slate Plan I.D. Number/ <br /> In accord with Comm 63.21, Wis. Adm. Code,personal information you provide I (05 <br /> may be used for secondary purposes Privacy law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel N Lot N Block N <br /> ,j 1 e) W /9-•J 0/6 -- 3 zl -0 0 <br /> Property Ow 's Ma iling Address / r Property Location <br /> �el /¢f Q e-(/ d /J t_ u,S't.J it,Section 3D <br /> City,State ..II � / Zip Code Phone Number �.�( <br /> Gr'9wT5`H/r W7� `S��yU T�N; R� / Eoe�V <br /> II. Type of Buildin (check all that apply) <br /> �1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City ❑Vdlige;PIT-ownship of <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑ New System 42Re lacement System y p y ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification m Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision El Change of 11 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Mound > 24 in.of suitable soil IK 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. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> / S— 300 3oC) <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 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin 1) 1 Plumber's Signa ture MP/MPRS Number Business Phone Number <br /> Z ) 4d*-- 1 gr24. m I /A) _ 22769 3 - <br /> Plumber's Address(Street , City,State,Zip Code) <br /> toxS/ SGJ� s`faP7� <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dau Issued Issui nt Signa o Stamps) <br /> Surcharge Fee) f U1r 0� <br /> ❑ Owner Given Reason for Denial 1' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> WI wND V061646 - V&V64io $ * 0� <br /> Attach complete plane em the County only)to,the.yaem on pope,not nese thin,evz x u inches in size <br /> SBD-6398 (R. 01/03) <br />