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Safety and Buildings Division County n <br /> IN 201 W. Washington Ave., P.O. Box 7162 rlYC <br /> Nsconsin Madison,WI 53707-7162 Sanitary/PIer^ 7 <br /> Permit Number(to be filled in by Co.) <br /> Department of Commerce 0)266 3151 53 1 8 <br /> Sanitary Permit Application State Plan I.D. Number <br /> In accord with Comm 8321,Wis.Adm.Cade,persotal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(l)(m) Project Address(it different than mailing address) <br /> I. Application Information-Please Print AH Information �� / C <br /> Property Owner's Name � ``�� Parcel# lk Lot# Block# <br /> fol SCj1/�/f ey�" CSGh m ld� fa—M, 02 //60/ 10 <br /> Property Owner's Ma iling Address Property Location <br /> 07 old( /D 0n► eL4 /S <br /> City,State /^ Zip Cade Phone Number p� /�J}q� °f—� .Sectiones <br /> CA, lit, 55ot3 GSA ZS7�XJG T lV N: R�EodW/) <br /> ,I1.Type o uilding(ch k all that apply) C <br /> IU 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Publia/Commercial-Describe Use `-si5% <br /> ❑State Owned-Describe Use ❑City_❑Village %T'ownship of4&>e�of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) * _0y$.Z_*D_/2j,-6_ Q6-001-0J6= <br /> A' ❑ New System cR Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification in Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ 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 I ) <br /> 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 Talc ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Lire ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> k� - 7 yZ C ((00) I'A6 <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 /> Trraynrkr�s Tacks <br /> Septic or Holding Tank /Mn 1 <br /> Aerobic Treatment Unit wV <br /> Dating Chamber <br /> VU. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P tier's Name int Phut 's Signa ture MP/MPRS Number Business Phone Number <br /> Lsk oo, ) /°/S`/ j(-71'5) .6e6— ,9070 <br /> Plumber's Address(Street ,City,State,Zip( e) <br /> Z 7Z2o J aur cl QeL6>/- ,W6-5�t8 <br /> VM. County/Department Use Only <br /> bi Approved ❑ Disapproved Sardnry Permit Fee(includes Groundwater Date Issued Issuing Signature( tamps) <br /> Surcharge Fee) 3.25 <br /> 2 590 .10�D <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapprgval <br /> D �C� dC� <br /> SEP 2 9 2010 ff <br /> BURNETT <br /> Attach complete punt(m the County only)for the system on paper not iris than 8112 x it inches in siZONING <br /> SBD-6398 (R. 01/03) <br />