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Safety and Buildings Division County J <br /> NVisconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 l�fN6 Madison,WI 53707-7162 Sanity Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4383') S <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information 8 [� <br /> / O'C l ,t'f J a /L�.1 <br /> • <br /> Property Owner's Name Parcel]# J LLot# (; Block# <br /> wolf)lac hr el-i orzw #,;W 05-/06 6,L, 5 <br /> Property Owner's Mailing Address Property Location <br /> '10 E tl 7/L Ve, V, Section <br /> City,State / Zip Code Phone Number <br /> '� Q.lel WAW rj 72 6/2 66 _1162 z T V N, R/6(`Econ° <br /> II.Type of Building(check all that apply) <br /> IQ 1 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> CSM Number <br /> ❑Public/Commercial-Describe Use VO` g l / <br /> ❑State Owned-Describe Use ❑City_❑Village OTownship of Oat 'M- <br /> ITI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. q New 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 Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> 19 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevatipn N <br /> 340 S X46 6w 95-_ ��'7 3 s <br /> VI.Tank Info Capacity 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 <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 Business Phone Number <br /> 609s - 2ZSgS7 1)5b- <br /> umber's Address(Street,City,State Zip ode) <br /> s- kky <br /> VIII.County/Department Use Only <br /> Sanitary Permit Fee ncludes Groundwater Date Issued Issui t Sign o Stamps) <br /> Approved ❑Disapproved Ile- <br /> Surcharge Fee) ; (, <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ?., 20p l <br /> ,f.�� 3ON 01jAl <br /> 'Ale, ivry <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x It inches in size <br /> SBD-6398 (R. 01/03) <br />