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Safety and Buildings Division County <br /> 201 W.Washington Ave. P.O.Box 7162 l�� #1 e 71 '_ <br /> Y�A <br /> Madison,WI 53707—7162 Sanitary Permit Numberbe filled i to <br /> (608)266-3151 ( n by Co.) <br /> Department of Commerce ' <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.211 Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property � y <br /> pe y Owner s Name Parcel# Lot# g6 Block# <br /> o,� 460 0 0�(, ad <br /> Pro i l d e e t�i✓L <br /> Property Owner's Mailing Address S <br /> Property Location <br /> /fd 0 �r�11a wi Al+c � d4 OQ <br /> City,State Zip Code Phone Number -----'�4, `fie, Section <br /> St- /0 Al .1-0 SOW to &S-i 330-'7,.s-o <br /> (circle one) <br /> II.Type of Building(check all that apply) T %o N; R/;EE oo <br /> ®1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> Public/Commercial-Describe Use e1 <br /> U.— <br /> El State Owned-Describe Use ❑City ❑Villa e ETownshi of <br /> .- g P �a G k„se h <br /> III.Type of Per (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> LE New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification canon to 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 apply) <br /> WNon-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade <br /> ❑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 ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> .3�o y <br /> • ?S'o JI <br /> VI. <br /> �t <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Plastic <br /> Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 1TOO aQa Z S� <br /> 4 0 <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 1 <br /> Plumber's Name Print pans. <br /> (Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> h s �?ft 0_e_� p��S �`�`l 7/S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> V11.Coun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued IssuirM Agent Signature(No Stamps) <br /> Surcharge Fee)❑Owner Given Reason for Denial �. C� 6-3(0-0(0 , <br /> IX.Conditions of Approval/Reasons for Disapproval <br />