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I <br /> Saler. and Buildinei Di%i,wil Giun1, <br /> 'U 111 %k j,hln4ton A%e. P 0 Bol 71 n' U <br /> isconsi / ftlddl;un. 11'I 53'II'- 7lo? Cf <br /> JaI11Wr'• ('cnnn \unibcr(111 be tilled m b•. trot <br /> Department of Commerce (608) 260-3151 �77D <br /> Sanitary Permit .application "'fe Plan ID -Nnnlber �� <br /> In accord woh Comm 83 21,111;. Adm.Code,personal information you prmide r�W <br /> olay be mod lit,secondary,purpose,Pma<y Law.sl i )At NnU v <br /> Pnycct AJdrc„iii dd(ercm rtlan niadmg address) r� <br /> %pplication Information-Please Print:UI Information <br /> Prupeny Owner's Name 55 •' <br /> Parcel a Lot a Block 4 <br /> Property Ownzr s Mailing Address 036 Hz1/ Ol <br /> Property Location <br /> Zt337� 5 G C-�ov 1("(IDT (o <br /> City.sidle Zip Code Section lj H <br /> Phone Nwnber —� <br /> qN�Qf t. - - Sit circico I <br /> II.Type of wilding(check all that apple) T �U N. R E or <br /> I or?Family Dwelling-Number of Bedrooms 3 <br /> ISubdi,islon NameCSM1I Nwnber. <br /> ❑ Public Commercial-Describe Use Ltz(( a,Csm yea(�p 70 <br /> ❑Stale Owned -De,crlbt Use ❑Gry_❑b'dlagr�Tow nshiPof Q^JI6" <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> Now Sysrzm ❑ Replacement System ❑ Treatment Holding Tank Replacemrm Only L-1 Other Modification to Existing System <br /> 9. ❑ Permit Rencwal ❑ Permit Res ision <br /> ❑ Change of ❑Ptrnw Transfer w New List Previous Permit Number and Date h;uzJ <br /> Before Expiration Plumber <br /> Owner <br /> 1%.Tv a of POM1M1TS Svstem: IlEneck all that apply) <br /> QNon -Pressurized In-Ground ❑ Mound>Iq inof suitable sod ❑ Mound<24 inof suitable soil ❑ At-Grade ❑ Single Pass Send Filter LJ <br /> Constructed 1i'riland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Symhetm Media Fiha ❑Leaching Chamber ❑Drip Linc ❑Grasel-Ie,;pipe ❑Other Inplam) <br /> V. Dis crsal/Treatment Area Information: <br /> Design/F1'ow Igpd1 Design Soil Application Ratelgpdstl Dispersal Area Required(st) Dispersal Area Proposed Ism System Elevation <br /> O ' 900 qac 76 7 <br /> %1.Tank Info Capacity in Total Number lilinufacturer <br /> Gallons Prefab Site Steel Fiber Plastic <br /> Gallons of Umts Concrete Cons«ucteJ <br /> New Existing Glass <br /> Tanks Tanks <br /> $epnc or HulJmg tank <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VIL Responsibility Statement- 1,the undersigned,assume responsibility for installation of the PO%%TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MI'M1IPRS Number <br /> Business Phone Number <br /> k1clord7 <br /> nLily. 585') 7/S 6 <br /> Plumber's Address IStre , ty,State,Zip-Code) <br /> Z17O We rl <br /> VII .Count%/ c ar ment Use Onls <br /> Approved ❑ Disapproved San iary Pennrt Fee(includes Groundwater Date ssucd Issc.ng A en ignature i.. mps) <br /> Surcharge Fee) � ��oy 0 r <br /> El Owner Given Reason for Denial 5O (1� <br /> I\.Conditions of.ApprovaliReasons for Disapproval <br /> ( j <br /> I UAY <br /> BUpNETTC <br /> OUN <br /> Attachm <br /> cuplcte plans po the County onlf)for the s,%ten,an paper not less than a1:2 s 11 inches in site ZONING <br /> SBD-6398 (R. 01/03) <br />