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Safety and Buildings Division Coun - ., <br /> 201 W.Washington Ave.,P.O.Box 7162 ry�y/'N <br /> 1[ G <br /> isconsin Madison,WI 53707-7162 Sanitary PgrmitNumber(to be filled in by Co.) <br /> ent of Commerce <br /> (608)266-3151 z178'50_c5- <br /> De artm <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.2 1,W is.Adm.Code,personal information you provide /3 q <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information v) <br /> Property Owner's Name ,,L Parcel# Lot# Block# <br /> An) E � l, ( /9- ::2- <br /> Property Owner's Mailing Address Property Location <br /> '£ � <br /> y;L 5— s 3 <br /> � Ve �� �� � <br /> City�rsteZip Code Phone Number �_ —�= Section�— <br /> S 1eel/l 4,Ak, -1--ye7 ,.T 3lS� N; RIPE E cle e) <br /> II.Type of Building(check all that apply) o <br /> or 2 Family Dwelling-Number of Bedrooms <br /> Stiy'�Wgni liam- CSM Number <br /> ❑Public/Commercial-Describe Use Vz 3 c) <br /> ❑State Owned-Describe Use '� ❑City_❑Village NFownship of_4 41F, e7� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System 2161acement System ❑TreatmenUHolding Tank Replacement Only 11 Other Modification in Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Mound>24 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.Dns ersaVTreatment Area Information: <br /> Designn Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Toml Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> $pptic-or Holding Tank / A <br /> Aerobic Treatment Unit O ,T <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana <br /> Plumber's Name(Pr t) Plumber's Signature MP/MPRS Number Business Phone Number <br /> w � �wFs�� .z -:7- Y <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .0 d )e S/y <br /> VIII.County/De artment Use On] <br /> ❑Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued lssuin g Sig o Stamps) <br /> Surcharge Fee) <br /> 11Owner Given Reason for Denial �p��-lJ <br /> CD <br /> IX.Conditions of Approval/Reasons for Disapproval / <br /> Attach complete plans(to the County only)for the ayatem on paper not leas than 812 x 11 mattes in nice <br /> SBD-6398 (R. 01/03) <br />