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Safety and Buildings Division County <br /> // <br /> 201 W.Washington Ave.,P.O.Box 7162 e_ <br /> rK T _ <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in <br /> `�seonsin by Co.) <br /> (608)266-3151 LL G 1 O <br /> Department of Commerce ! J 1 <br /> Sanitary Permit Application Slate Plan LD Number <br /> In accord with Comm 83 21,Wis.Adm.Code,personal information you provide /14) / o <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing Mdr1ess) <br /> T. Application Information-Please Print All Information X07/0 �2tit'-ISP �Ae.tY Rd�N <br /> Pro env ner's OwName O Parcel N Lot 4 Block p <br /> wl w«0vMa 3 - -3 <br /> II Property Owner's Mailing Address Property catioon(/, , Section�2 <br /> � <br /> r\^/0 04,e� ))C <br /> Zip Phone Number <br /> ?�,/ P <br /> Qt <br /> T <br /> II.Type of Building(check all that apply) RLE a'S< -- <br /> Ior2FamilyDwelling-Number of Bedrooms Subdivisioonn Name CSM Number <br /> Public/Commercial-Describe Use <br /> .J State Owned-Describe Use OCity_JVillage Township o ¢ <br /> 111.-Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> New System J Replacement System J Treatment/Holding'Tank Replacement Only J Other Modification to Existing System <br /> B. l._ Ferran Renewal J Permit Revision ❑ Change of J Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> �V.Tvpe of YUWF System: (Check all that apply) <br /> r) Non-Pressurized In-Ground J Mound>24 inof suitable soil J Mound<24 inof suitable soil J At-Grade J Single Pass Sand Filter 1 <br /> I Constructed Wetland JPressurlwdln-Ground .Holding Tank El Peat Filterg �..! <br /> ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> Remrcu!anng S}ntheuc h:cdia Filter J Leaching Chamber a Drip Line J Gravel-less Pipe J Other(explain) <br /> V. Dis ersal/I'reatment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Tiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks _ <br /> SepticHold-&Tank 7-00O 1e fn x <br /> Aerobic eammnt knit <br /> rasing Chamber <br /> VII.Responsibility Statement- 1,the u dersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name Pri t) PI mber's Sign MP/MPRS Number Business Phone Number <br /> 4 zzszZ 7•�d�6�Go <br /> Plumber's Address(Street,City,State,Zi Code) <br /> UYs r SY793 <br /> VIU.Coun Ne artment Use Only <br /> _ Approved J Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Ignatur o Stamps) <br /> Surcharge Fee) x <br /> ❑ Owner Given Reason for Denial <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> I I <br /> J <br /> Attach complete plum B.the Coonty oaly)for the system on paper mt less than 812 s 11 inches in sire <br /> S) D-6398 (R. 01/03) <br />