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Safely and Buildings Division County <br /> 201 W.Washington Ave.,P.O. Box 7162 u"- <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce <br /> (608)2663151 55 11 00 <br /> Sanitary Permit Application Statellan I.D. Number ll <br /> In accord with Comm 83.21.Wis.Adm.Code,personal Information you provide rntiCU kI <br /> may be used for secondary purposes Privacy law,sl5.04(1Xm) Project Address(if different Than mailing address) <br /> 1. Application Information-Please Print All Information 11� <br /> Pro Owner's Name 77 07' 2'2.4o-I S-(j tS 16•�/��O$O�WO <br /> �t <br /> PropertyMiter's Ma illAddress Property Location <br /> Z/ tWood // Pr <br /> K• 16,Section <br /> City,S Zip Code Ph"Number <br /> cv - L N 55i 5!l 109 ��-ccuctc o <br /> 11.type of Building(check all that apply) T�N; RAE o ' <br /> Dr,or 2 Family Dwelling-Number of Bedrooms Z Subdivision�Name �� CSM Number <br /> 11PubticlCommercial-Describe Use O�CL1 1�A" A / <br /> A . 4+ tlIlaxv 06s3e <br /> ❑State Owned-Describe Use ❑City_❑village NTownship of 1q& <br /> III.Type of Permit: (Chercck,only one box on tine A. Complete line B if applicable) <br /> A' E] New System tp Replecerttera System Q TrmmrM/ffaldimg Tarok Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Doge of ❑Pond Trarafer to New Inst Previous Permit Number and Dare Issued <br /> Before Expiration Plumber Ownv <br /> IV.Type of POWTS System: (Check all that y) <br /> ( Non-Pressurized In-Ground ❑ Mound > 24 in.of suitable sail ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Saud 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 Lire ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersalffreatment Area Information: <br /> Design Flow(gpd) Design Soil Application R Wocist) Disposal Arra Required(st) Dispersal Area Proposed(sfl EI do <br /> Sod • 7 y2� y/A40 . w �zr <br /> VI.Tank InfoOpacity in Total Number Matnufacmrcr Prefab Site Steel Fiber Plastic <br /> Galimns Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank 060 ow <br /> i <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assinee rrsponsibd6y,far installation of the POWTS shown on the attached plans. <br /> PI is Nam( n t) 'b Sign MPIMPRS Nwnber Business Phone Number <br /> on T 7'a� 85/�tSL/ r/57 G6-6b7o <br /> Plumber's Address(Street ,City,Sate, ode) <br /> 97ZZo Wt' y�y <br /> VII County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signatr Stamps) <br /> Surcharge Fee' 3 2 5� t lo it <br /> IJ Owner GivenReason fm Derrial <br /> IX. Conditions of Approval/Reasons for Disapproval 7 <br /> Attach compMe pins(to the Corq mly)for the systems r Aper not ka ohm 81t2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />