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Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 k r/1 <br /> �seons�n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 �QCI�Q <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(I)(m) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Information ? <br /> C • 3� y`�gs,•llrGr �rrch jrw <br /> Property Owner's Name Parcel# Lot#3L4 Block# <br /> CA&ce- ' N.f�lawa Old 9600 04400 <br /> Property Owner's Mailing Address Property Location <br /> 9338 1aa/ate L.rt ,f/. <br /> City,State Zip Code Phone Number —�A• —��• Section AA <br /> ms's < [suave /+'1A/. s✓�// G/,l �.G9-G/9,6 (circleo <br /> T�tO N; R/S Eort�J <br /> II.Type of Building(check all that apply) <br /> I ort Family Dwelling-Number of Bedrooms i( Subdivision Name CSM Number <br /> ❑ S�^ l ,1 I/,IR,W'� <br /> Public/Commercial-Describe Use r <br /> ❑State Owned-Describe Use ❑City_❑VillageegTownship of.Jo.e./<9on <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification 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 ofPOWTS System: Check all that apply) <br /> M 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 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(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(at) System Elevation <br /> 300 • 7 1 Yd9 TA J1,1-7 a. 7 <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 /> Septic or 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(Print) Plumber's Signature MP/MPRS Number <br /> /L Business Phone Number <br /> 1G k He iN J i2ro .Q H } 8".�/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 147764 WY 3.r" We6sfFei tum g yt 893 <br /> VIII.Coun /De artment Use find <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing a ignamre( mps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial 1 �x✓T/� Gft�/rL p� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County unity)for the system on paper not but Man 812 s Il inches in we <br /> SBD-6398 (R. 01/03) <br />