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Sldcly and Buildings Division County <br /> ` 201 W.Washington Ave.,P.C. Box 7162 Z4 "/J e— <br /> i5c011$i/1 <br /> Madison,W1 53707--7162 Sanitary Penn itNuntber(iohefilled inbyCo) <br /> Department of Commerce (608)36631?I S12/039 <br /> Sanitary Permit Application Slate Plan l.D_Numrer --� <br /> I accord with Comm x3.21,Wis.Adm.Cuda,personal inlir matit)nyou provide <br /> may be used lot secondary purposes I'nvnry I im,.15.04(1)(n) Project Address(it diflerenl than mailing address) <br /> 1. Application Information-]Tease Print All Information nT r <br /> Property Owner's Name (� Parcel 4 lot M Block N <br /> �CCevcl owne.✓: �I�I�N G �SlzlOn <br /> Z/ P rd ti � 03;7- S-:,?P6 o6116 <br /> Property O er's Mailing Address Property Location PC-/ G e r 'J <br /> _ 30,2 " s /,o f So��sa.J �� Section <br /> City,Slate Zip Code Phone Number <br /> -1I S p7 ,(utcico ) <br /> /U lJ ✓s � O J � I �N; RLJ I'n Wi� <br /> 11.Type of Building check all that apply) <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑Stale Owned-Describe Use OCay—Uvillage�Tewnship of <br /> 111.Type of Permit: (Check only one box on line A. Complete line 13 il'applicable) <br /> A. <br /> X_Kpw System ❑ Replacement System ❑ 'frcutuunl/I InlJing'fank Replacenrem Only ❑ Other Modillcalion to Existing Syslan <br /> B• D Permit Renewal D Permit Revision D Charge of ❑I'ei tirt I'rnnsler to Naw List Previous Permit Number and Dale Issued <br /> Before Fspiralion Plumber Oster <br /> IV.Type of POWTS System: Check all that apply) <br /> ANon-Pressurized In-Ground D Mound>24 in,of suitable sod D Mound<24 in.of Suia lIC suit 1.1 At-Grade D Single Pass Sand Filter D <br /> Constructed Weiland D Pressurized In-Ground n I Inlding'I aak D Peat Filter D Acrobic I Temnrcnt Unit D Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter U Leaching Chamber V Drip Linc U(iravel-Icss 1'ipc (-I Other(c,eploin) <br /> V. Dis elsalffreatment Area Information <br /> Design Flow(gpd) Design Soil Application Re e(gpdsl) Disposal Area RCLIUired(s0 Dispersal Arca Proposed(SI) System Flevalion <br /> 9 _� <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New llsisnng <br /> 'finks 'Tanks <br /> scphe or 1lejdialS�Fmk pOd — /'dDU — -G/Iy e— — <br /> Acrohic'Rcatmcnt Unia <br /> Dosing Chamber <br /> V11. Iles po ns i b i I ity Stail tile"t- I,the undersigned,as'snFite responsibility for incl:dlala it of the I'OW hS shorn an the atlached plans. <br /> Plumber's Name(Print ]'lumber's Signature MP/MPRs Number Business Phare Number <br /> w AA <br /> ]'lumber's Address(Street,City,State,Zm Cade) <br /> e�Jr -574 <br /> Vill.Countv/De m•tment Ilse Dal <br /> Soninry Permit Pec(includes GrninJtener Dnle Issued Issuing :ignalure Ways)Approved D Disapproved Surcharge Fec) <br /> ❑Owner Given Iaaason Iia Denial ' <br /> IX.Conditions of Approval/Reasons for Disapprnral <br /> AIWIF tomplem pl:uu(ill the Cnunay ooh)for the sysmm on paper not less than 81/2 s 11 inches in size <br /> SBD-6398 (R. 01/03) <br />