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Safety and Buildings Division County '7 <br /> 201 W.Washington Ave.,P.O.Box 7162 S f t r„ f F <br /> N*isc.onsin <br /> Madison,WI 53707-7162 Sanit7- 393-32- <br /> of <br /> Permit Number(to be filled in by Co.) <br /> (608)266-3151 7- 3$ 3 of Commerce 3 Z <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> maybe used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information / <br /> <_Oun+/ 11e•e fi0l• <br /> Property Owner's Name / Parcel# Lot# Block# <br /> John W'll 1 < (� /U [ ;Z8--T86-nl-dna . <br /> Property Owner's Mailing Address Property Location -2y��o-/,_ I O„ ( n_ <br /> !4 734 /3occf ter R n 2 1Vw y,, Nl�'Ys, Section -3(o �l <br /> City,State Zip Code ::[Phone Number qo <br /> Ed le ol PrAl rite m N S6"3 47 (circle o ) <br /> II.Type of Building(check all that apply) TN; R 14 E ot� <br /> .14 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 X]Township of Ro1Q. <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. Ll Permit Renewal El Permit Revision L1 Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> X 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(gpdsf) Dispersal Area Required(sf) Dispersal Area Pproposed(sf) System Elevation <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 I Tanks <br /> Septic or Holding Tank MOO Q W <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 /> PI e-& Roe/c(;, s [4 22S8S/ 7fS- S6(n-ci/S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> nl7760 //� 70 Ole,6s1 r✓ wl's"tfg4 3 <br /> II.County/Department Use Only <br /> Approved Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu' ent Si a(No Stamps) <br /> Surcharge Fee) /( ,l <br /> ❑Owner Given Reason for Denial a C/ v' AU6 os <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> J 4tlo vvvCV <br /> e�9NF � l <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in si ON 0 <br /> ANG U�� <br /> SBD-6398 (R. 01/03) <br />