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. A <br /> Safety and Buildings Division County Bu <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Visconsin Cl\ <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application state Plan I.D.V Number Q a <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide �3 O`�Wr, <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> V0 M <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name (� Parcel# Lot# Block# <br /> �� �--r D 33.5-Os_sbo <br /> Property Owner's Mailing Address Property Location llJn 1- /'av T Lv 1 3 <br /> LQ• �t on S <br /> City,Sta Zip Code Phone Number ��'� �', Section J� <br /> (1,� fh (circle o <br /> I I L T�N; R�..EE or� <br /> II.Type of Builth (chec all that apply) <br /> El or 2 Family Dwelling-Number of Bedrooms Subdivision Name L.OT 4 CSM Number <br /> i <br /> ElPublic/Commercial-Describe Use s , <br /> 11 State Owned-Describe Use ❑City_❑Villageownshipof a <br /> IIl.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. El Permit Renewal El Permit Revision 11 Change of 11 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <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 AHolding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <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 /> Tanks Tanks <br /> $ap4a.uc Holding Tank <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin Plumber's Signature MP/MPRS Number Business Phone Number(3A 0103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> S1 m/ <br /> IL County/Depar1ment Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued lssui Agent Signature(No Stamps) <br /> pproved ❑ Disapproved Surcharge Fee) 4�Cu � l� r� <br /> ❑Owner Given Reason for Denial Vll •I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />