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Safety and Buildings Division County / <br /> 201 W.Washington Ave.,P.O.Box 7162 (NP�1 <br /> Vrisconsin Madison,WI 53707-7162 Salutary Permit Number([o be filled in by Co.) <br /> Department of Commerce <br /> (608)266-3151 S51 170 <br /> Sanitary Permit Application Stare Plan I.D"Number � <br /> In accord with Comm 83.2I,Wis.Adm.Cade,personal Infmmatbn you provdc R <br /> may be used for secondary purposes Privacy Law,s15.04(i)(01) Pmjeci Addr (if different th=mailing address) �J <br /> .11 <br /> 1. Application Information-Please Print Ali Information/' 3S'-79 �V 2Z�ef� 7U/1�rnL <br /> Property Owner's N Parcel p Lot f /_ Block N <br /> Jit et �' D129576�/ 00 U <br /> POw 's Ma iling Property Location <br /> X270`271 Ii, -k,Section_ <br /> City,State Zip <br /> /1� I' /,�f'//� Zip Cade Phare Number <br /> NOI f '/ V%k ////V �Z �i�2 �O� T "/D N; R Eclo N ) <br /> 1I.Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms I <br /> ElPubiic/Commercial-Describe Use - � '" r�' <br /> ❑State Owned-Describe Use ❑City_❑village m <br /> VTowhip of 9-A <br /> III.Type of Permit: (Check only one box on line A. Complete lice B if applicable) �� - 7and <br /> � <br /> A" ❑ New System Replacement System ❑Treatment/Howi%Tads Replacement Only ❑ Other Modification to tem <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Charge of ❑Permit Transfer m New list Previous Permit Nume Issued <br /> Before Expiration Phmtber Owner <br /> IV. of POWTS S ivu: (Check all that ) <br /> 1W Non-Pressurized In-Ground ❑ Mamd > 24 in.of suitable soil ❑ Mound < 24 in,of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Consmicted Wedand ❑ Pressurized hi-Ground ❑ Balding Tank ❑Peat Filter ❑ Aerobic Ttamrent Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Lure ❑Gravel-las Pipe ❑Other("Plain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ramat) Disposal Ars Required(at) Dispersal Area Proposed(sf) I SW Elevation <br /> 300 r$ 6Gd -G©0 0 9260 <br /> VI.Tank Info Capacity in Total Number Mandacroser Prefab Site Steel Fiber Plastic <br /> Gallons Galicia of Units Concrete Constructed Glass <br /> New Fsiuirg <br /> Tanks Tads n <br /> Septic or Holding Tank 750 7W <br /> Aerobic Treatners Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for bion of the POWTS shown an the attached plans. <br /> PI bet's Name fPr�`m t)) 's Sigoa MPIMPRS Number Business Phone Number <br /> %114rvlev <br /> Plumber's Address(Street ,City,Stare, Cale) <br /> Z72;70 74/t7i eiJ e&314"Lj S <br /> VIII.Com /De ent Use Only <br /> Approved I ❑ Disapproved Sanitary Permit Fee(includes Gtomdwner Date Issued Iss ' i (No Stamps) <br /> ❑ Owner Given Reason for Denial Suroduarge Fee) �' a5 �'a, <br /> IX.Conditions of Approy"easons for Disapproval 1 <br /> SEP 1 2 2011 <br /> Attach cnaplete blazes(to tae Cavy odic)roc the s}s/ea a paper not les;that Sia x II inches in ZONING <br /> SBD-6398 (R. 01/03) <br />