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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 UrNef� <br /> V'sconsin Madison'M 53707-7162 Sanitary Permit Number(w be Glled in by Co.) <br /> (608)266-3151 53 z 150 <br /> Department of Commerce <br /> Sanitary Permit Application San Plan LDgNumbe <br /> In accord with Comm 83.21,Wis.Adm.Code.personal infer anion you provide 16,779/ , <br /> may be used for secondary purposes Privacy law,sl5.04(1 Xm) Pro t Address(if different than mailing address) <br /> 3�0 2GLI`nbbW CirGIC, <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel a Lot A �, Block a <br /> er- e- on- ?575-rift <br /> Property 6 O�^is M flingAdddress Property Location <br /> 1 1 I/t1[4(`—oIh Vh Section �t% <br /> City,State Zip Code Phone Number <br /> �/ ',�crrcle e) <br /> Uf rtr+ t OZB�(J S 2 3 T NDN; R�E a�V <br /> II.Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> 111 or 2 Family Dwelling-Number of B(eJd�room1s L� I / 1 / <br /> XPublic/Commucial-Describe Use atX071(Ik7Y) ho V-f- �InboLJ ��. V' V� <br /> 11 State Owned-Descnbe Use ❑City_❑Village�prownship of <br /> 111.Type of Permit: (Check only one boa on line A. Complete rise B if applicable) p -CQ <br /> A' ❑New System weplecement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> 8. ❑Permit Renewal 11Permit Revision ❑Change of ❑Permit Transfer to NweLiu Previous Permit Number and Date issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> DkNon-Pressurized In-Ground ❑Mound>24 in.ofuntabk soil ❑ Mound<24 in.of suitable sail ❑M-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑Pressurized In-Ground ❑ Holding Tank ❑Peat Fiku ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-)est Pipe ❑Other(explain) <br /> V.DIs ersaVTreatment Area Information: __ <br /> ���w(Bpd) Design Soil Application Rate(gpdd) Dispe�Arw�equired(st) Dispersal Area ed(sf) System Elevation <br /> Vt.Tank Info Capacity yiin Total Number Manufacturer �`77jj Prefab Site Set, Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New En mg <br /> Tanks Tanks <br /> Septic or Folding Took /ooD i /0 I/ �( L� <br /> Aerobic TreatmeN Unit �f <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility or inslallatioa of the POWTS shown an the attached plaus. <br /> PI is Name(Print) Plum 's Signature MPIMPRS Number Business Phone Number <br /> 851�i5 �� 866-811�o <br /> Plumber's Address(Street,City,State,Zip Code) <br /> H.Coun /D artment Use On! <br /> pproved ❑Disapproved Sanitary Permit Fele(includes Groundwater Date Issued Issuin Agent Signature(No Stamps) <br /> Surcharge`e $3Zi& OD VXli..n <br /> ❑Owner Given Reason for Dubai ��4----+NNN�f i�7. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Abash eompkte Plass(to the County only) or the syren on poW on,Inn than 1112 x I I imins,in sive <br /> SBD-6398 (R. 01/03) <br />