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Safely and Buildings Division County�� N <br /> ' <br /> VVIsconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 �Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 7 <br /> 942 �3 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide f 1 Q <br /> may be used for secondary purposes Privacy Law,sl5.04(I)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information 70 <br /> of - 202-oz-5�b <br /> Property Owner's Name Parcel# Lot# Block# <br /> Vopeny 10 4 A)Own fling Address a� A- / ,-,L, z <br /> Property Location <br /> Ci�ty,/State/ Zip Code Phone Number —p�_ —. y'=+�Ec µSection <br /> !�"�i6G�/ L✓ 5��� 3 T�O N; R�� lene <br /> II.Type of Building(check all that apply) ,. <br /> Lr 2 Family Dwelling-Number of Bedrooms `7` Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use I.... <br /> ❑State Owned-Describe Use ❑City_❑villa splof <br /> /of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑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 I I Plumber Owner <br /> IV.T e of POWTS S stem: Check all that a I <br /> ❑Non-Pressurized In-Ground 171FIbund 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 ❑Gravel4ess Pipe ❑Other(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info C pacity 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 /20C) <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 /> Business Phone Number <br /> Plumber's Address(Street,City,State,Z Code) <br /> �6X s/ � e �- �✓ S5/�' 2 <br /> rLXC,,Odit,o,, <br /> Cun /De artment Use Onl <br /> proved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing or Si re ps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> of'Approval/Reasons for Disapproval <br /> Attach complete plain(lo the County only)for the system on paper not Ids than 812 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />