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I <br /> tl <br /> Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 t.,yN/v2 <br /> iseonsin Madison,WI 53707-7162 Sanita7 Permit Number(to be filled in by Co) <br /> De artment of Commerce (608)266.3151 1. 10 <br /> Sanitary Permit Application State Plan I.D.Number , <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(Ixm) Project Address(if differentthan mailing address) l}�UeGS/ <br /> 1. Application Information-Please Print All Information Lel / j <br /> ( v ho"< �(p e �eoet. ey, <br /> Property,��wner's Nemcll Parcel q Lot q Block q <br /> Property Owner's Mailing Address •• Property Location <br /> a. /1vr�e ka(. 33 <br /> _Itty'State 1 /!•1 Zip Code Phone Numbeerr ��p.A•��j�(A• Sxtion <br /> CO.N(-•6 //-FL PO V p .36// 77U -O 3a ./06 �/ 1( aircle.1 <br /> II.Type of Building(check all that apply) �7 T_N; R_E o� <br /> JVI or 2 Family Dwclling-Number of Bedrooms 3 SubdivisionNameCSM Number <br /> ❑Public/Commercial-Describe Use 6TH a -a 3.7-O <br /> ❑State Owned-Describe Use ❑City_❑Village Township of <br /> S. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 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 Pmvious Permit Number and Date issued <br /> Before Expiration Plumber Owner <br /> IV.T e of POWTS S stem: Check all that a I <br /> �i Non-Pressurized In-Ground ❑Mound>24 in.of suitable snit ❑Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Pea[Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filler ❑Leaching Chamber ❑Dri Line ❑Gravel-less Pipe ❑Other explain) <br /> V.Dis ersa VFreatman(Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Mee Required(so Disp l Aree Proposed(so System Elevation <br /> s-� 6Y3 6 ?, t/�• <br /> V[,Tank Info Capacity in ' Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Plastic <br /> New Existing Concrete Constructed Glace <br /> Tanks Tanks <br /> Septico holding Tank <br /> aaa t.s <br /> m Trurment Unit <br /> Dosmg Chamber <br /> VII.Responsibility Statement- 1,the underfigned,auu responsibility for lustaltatfon of the POWTS shown on the attached plans. <br /> Pnlu.m� ber'g Name(Print) r PI�bbe�r s Si ature hWM1PRS_N_ <br /> umber Business Phone Number <br /> /•f4>l` �4ea�'rtvt. v/l o73�c�� 6 7/T L/ a -� 73 <br /> Plumber' Address(Street,City,State,Zip Code) <br /> VTII. nun /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued- Issit A Signatu Stamps) <br /> Surcharge Fee) C <br /> ❑Owner Given Reason for Denial � �5�� I9�J O J! <br /> IX. Conditions of ApprovaVReasons for Disapproval f <br /> Attach complete plum(to the County only)for the system on paper not iw than aliz a I I inches in site <br /> SBD-6398 (R. 01/03) <br />