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Safely and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 3"r n C, <br /> Asconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 47Z24 ), <br /> Sanitary Permit Application State Plan LD.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) ( {ti <br /> I. Application Information-Please Print AB Information <br /> Property Owner's Name Parcel# Lot# Block# <br /> cfAekd / o&&Y1 0)5- 33 — - <br /> Property Owner's Mailing Address Property Location <br /> /9 805 old -<Yy - A-I;d e <br /> S E y,, N� yy section I 1 <br /> City,State Zip Code Phone Number <br /> 60 &Aeoa^a rl In Al. <br /> SS-3H0 6/ -96s- 7s3 i (circle one) <br /> 11.Type of Building(check all that apply) T 39 N; R /b E or® <br /> ®1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑village IETowaship of Meerten <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. X 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 /> XNon-Pressurized hi-Ground ❑ Mound>24 in.of stumble soil ❑ Mound<24 in,of suitable soil ❑ At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Welland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Send 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(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> ys'o I . s 7419 1 Roi 17A-S- t o 92. o <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Exiting <br /> Tanks Tanks <br /> Septic or HoldTalc /00� <br /> ing /00 0 <br /> Aerobic Treatment Unit <br /> Dosing Chamber `off boa <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rtek yapB,hr /z - Jesssi -71s= 86`- 11/s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,17740 IYw 3f li/C6f rr Wl .S-'lP93 <br /> rV�IIIII.County/Department Use Ord <br /> iy Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing en gnaturc mps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach complete plain(to the County only)for the System on paper not less than 81/2 x 11 lattice In in <br /> SBD-6398 (R. 01/03) <br />