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Safety and Buildings Division Coun / <br /> 201 W.Washington Ave.,P.O.Box 7162 UrAJ,( <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ` Iscon5in <br /> (608)266-3151 A4r7 8 I ,1 <br /> Department of Commerce State Plan LD.Number �J�l <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide Project Address(if different than mailing address) r 1 t <br /> may he used for secondary purposes Privacy Law,sl5.04(1)(m) v)v} <br /> 1. Application Information-Please Print All Information QQ <br /> Parcel# Lot# Block# �f <br /> Property Owner's Name _ <br /> �( p olb v �� er- - on - i O <br /> Property Location <br /> Property Owner's Mailing Address <br /> / / ,I� r <br /> 183/ <br /> 8 Z/l bleleV (/C Section <br /> City, <br /> State ZIP Code Phone Number ct on <br /> o <br /> /Oe - ! S/ 6v8' "/-1" TN, R � cEoel� <br /> II.Type of Building(check all that apply) Subdivision Name CSM Number <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms <br /> ❑Public/Commercial-Describe Use ❑City_❑Villag a Difownship of IIVV6p0 <br /> ❑State Owned-Describe Use <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A' ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T of POWTS S stem: Check all that apPffi ❑ <br /> 1f Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑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 ❑ ❑Drip Chamber p Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dia ersaUTreatment Area Information: <br /> Design Soil Application Ra[e(gpdst) Dispersal Area Required(st) Dis ersal AreaP roPosed s� System Elevation <br /> Design Flow(gpd) Z` //3� a�•�� <br /> 30a <br /> Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> VI.Tank Info <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks Q <br /> Septic or Holding Tank v� / <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 hons.e <br /> Plu�mber's Name(Print) <br /> Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address( tree[,City,State,Zip Code) <br /> 27760 wY '5'-webs1-e1- L').• <br /> VIII.Cozen /De rtment Use Onl <br /> r�� Sanitary Permit Fee(includes Groundwater Date Issued Issuin Signam o Stamps) <br /> YA'Pproved ❑Disapproved Surcharge Fee) b �7 �' .' <br /> 11 Owner Given Reason for Denial ,G �4 U5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach Complete plow(to the County only)for the system on paper not Tess than silt x 11 inches to size <br /> SBD-6398 (R. 01/03) <br />