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Safety and Buildings Division Count <br /> 201 W.Washington Ave.,P.O.Box 7162 (`A yM+- <br /> lVisconsin <br /> Madison,WI 53707-7162. Sanita Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 5&6 7 ) \ <br /> Sanitary Permit Application Siete Plan I.D.Number !!00,1 <br /> In accord with comm 8321,Wis.Adm.Cade,personal information you provide W <br /> may be used for secondary purposes Privacy Law,315.04(lxm) Project Address(if different than mailing address) O <br /> L Application Information-Please Print All Information <br /> g vlg 33 . 9 o3 300 <br /> Property Owner's Name Place]# Lot# Block# <br /> %'^ er 2 ' 4 , Hogle- <br /> Property Owner's Mailing Address Property Location <br /> 7 7vd- L,)O Li d ;W y« t v w Y., Satin Z <br /> City,State Zip Code Phone Number <br /> L -f—to S rVtll).Lr. Si 3 c) (circle one) <br /> � <br /> II.Type of Bufidin (check all that apply) T NR lb <br /> RLI or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Naim 1//,CSM Number <br /> Public/Commercial-Describe Use ". aO4 <br /> [3 State Owned-Describe Use PTty— <br /> _❑ Wage Rrownship ofACQ ..C, <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ❑New System Peplacement System 0 Treatment(Hoiding Tank Replacement Only 13 Other Modification to Existing System <br /> B. 0 Permit Renewal 0 Permit Revision 13 Change of 1 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 ap 1 <br /> P-Non-Pressurized ht-Gtmmd 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil 13 At-Grade 13 Single Pass Sand Filter 0 <br /> Constructed Wetland 13 Pressurized in-Ground 13 Holding Tank 13 Peat Filter 13 Aerobic Treatment Unit ❑Recirculating sand Filter 0 <br /> Recirciablong Synthetic Media Filter ❑Leaching Chamber 13 Drip Line 0 Gravel-less Pipe 13 Other(explain) <br /> V. reatment Arra Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Arra Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 4 s-C) . 7 . (�Y2 1 C5 ? 95& y;p <br /> VI.Tank Info Capacity in Total Number Manufacture Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /006 l e7U<) rL X <br /> Aerobic Treatment Unit <br /> Dosing Clamber Epp loot) C.. K <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) tP 's Si MP/MPRS Number Business Phone Number <br /> Plumber's Address(S City,State,Zip ) J <br /> Al- <br /> ,V,�,,II//I.Cann nt se <br /> Only 117Approved ❑Disapproved Sanitary Permit Fa(includes Groundwater Date Isauin Si tamps) <br /> Sunt Fa �f M , <br /> ❑Owner Given Reason for Denial bye ) �t w � <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> r <br /> Two Cats*►w /ono Cmc✓o>✓ SEot e Ta�xr, Lb:rw Cfia..�.r Co�,•Kr6wL r� \VJ J <br /> 2003 <br /> i� JETT CQ1 INTY <br /> Attach complete plans(to the Canary only)for the system on paper not less than 81/2 x 11 Inches in siert ZONING <br /> ^ <br /> SBD-6398 (R. 01/03) <br />