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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 13"M K C'0, <br /> as 201 <br /> Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 <br /> Sanitary Permit Application Sate 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(l xm) Project Address(if different than mailing address) ll- <br /> I. Application Information-Please Print All Information in <br /> 3 Property Owner's Name a��� Gak,rJ v,�• <br /> Parcel# Lot# Block# <br /> .54APill,el r3n rM17LE l'yl Cad SJtb - �9 p <br /> Property Owner's Mailing Address <br /> `!3r <br /> Property Location / S <br /> LOT drf,.�,. st. V� l <br /> City,State Zip Code Phone Number _!/t —�/, Section A �P <br /> Rel a f.;/ip /yf N Sr//3 yeq 7 91 (circle e) <br /> 11.Type of Building(check all[hat apply) JJ T N; R i,!-'e <br /> All or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use s <br /> ❑City_❑ St. <br /> Village Township of rd <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> ❑New System XReplacement System ❑Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New Lis[Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T Of POIATS System: Check all that apply) <br /> )F Non-Pressurized In-Ground ❑Mound 124 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.Dis ars 1V ---tment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Sep 7 Yd9 -93A 'i <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Concrete Constructed Plastic <br /> New Existing Glass <br /> Tanks Tanks <br /> Septic w Holding Tank 7_ 7rD <br /> Aerobic Treatment Unit <br /> Dosing Chamber -SOO I <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of Me POWTS shown on the attached plans. <br /> Plumber's Name(Print) on <br /> Signature MP/MPRS Number <br /> Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) 66 f/i•S-7 <br /> 7�6 .f" eve6s�ri wS Srf <br /> II.Coun /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee f includes Groundwater Date Issued IssuiWAaent Signature(No Stamps) <br /> Surcharge Fee) (d\7!nN-nG P ) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval 'F� <br /> Attach complete plum(to the County 11 for the system on paper not Ins Mao art x I I inches ie aiu <br /> SBD-6398 (R. 01/03) <br />