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Ssfetand Huildrms Dtytson �) Com — _ <br /> ` � 301 W' blashington Arc. P.O.Ao.e lo= QWPH QJtf- ,I <br /> 53707 <br /> isconsiM � Nladis(6 WI 6-3151 '162 � Sanitary Permit Number Ito be hi c 1 in by la} <br /> /rc�� (608)266-315 i <br /> Department of Commerce <br /> Sanitary Permit Application S`a'e 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) Prgect Address(if different than mailing address) <br /> LI. Application.Inforciffilition-Please Print All Information tamp Dantel Or• <br /> Owner' Name Parcel# Lot 9-5- Block# <br /> M <br /> , koor,t'z oja -% D - <br /> Property Owner's Mailing Address Property Location <br /> YO Ar o/ivev 04ve s• <br /> Cit State 'A. _'/., Section /f <br /> Y. Zip Code Phone Number <br /> m /YIN S.Se'f/'/ 6/�� 9/•.S- /037 ((circle one) <br /> II.Type of Building(check all that apply) i��N; R fS E or� <br /> 9 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name) - CSM Number <br /> ❑Public/Commercial-Describe Use +��a'!1l <br /> ❑State Owned-Describe Use ❑Ci <br /> ty_(]VillageATownship of aGsfG.fe✓1 <br /> Eore <br /> mit: (Check only one box on line A. Complete line B if applicable) <br /> stem <br /> ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> enewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> iration Plumber Owner <br /> WTS S stem: Check all that apply) <br /> A Non-Pressurized N-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil Ci At-Grade ❑ Single Pass Sand Filter L <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ElLeaching Chamber ElDri E Line ❑Gravel-less Pipe LJ Other(explain) <br /> V.DiesersaVTreatment Area Information: <br /> Design Flow U) Design Soil Application Rate(gpdst) Dispersal Area Required(sfj Dispersal Area Proposed(so - System Elevation <br /> Al.ro • 7 6 93 1 6 f 9d 9 <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 /> /000 /000 L SEAW K <br /> Aerobic Treatment Unit <br /> Dosing Clamber <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 NumberBusiness Phone Number <br /> Y�5'- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77 ao Nw 3s We&ip ea- wT— s't 893 <br /> VIII.County/Department Use Onl <br /> A raved ❑ Disapproved Sanit�Pe"jtlincludes Groundwater Date Issued Issuin AaturePP pP g (I' amps) <br /> SurchD,�7 D K <br /> El Owner Given Reason for Denial / O ✓J <br /> IX.Conditions of ApprovaMeasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 it it inches ie slat <br /> SBD-6398 (R. 01/03) <br />