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Safety and Buildings Division County <br /> `40& 201 W.Washington Ave.,P.O.Box 7162 Qu el er�- <br /> isconsin Madison,Wl 53707—7162 Sanitary Permit Number(to be filled in by Co.) �A <br /> Department of Commerce (608)266-3151 49P, 3 11V <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 /> —v <br /> may be used for secondary purposes Privacy Law,s15.04(IXm) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Information !L - <br /> Property Owner's Name Parcel# Lot# Block# <br /> RicA.eoe 04ni-e/-r.an 3,` 4/5y <br /> Property Owner's Mailing Address Property Location C))a_q-7C <br /> '7301 s�ee.cPa A>e S I <br /> City,State Zip Code Phone Number —� —h, Section <br /> 43/eemin fnn OF?Al, S-ritJI 9S'.t-^01,t-91T9jcucle olle) <br /> " <br /> Il.Type of Building(check all that apply) T 0 N; R 4 E o <br /> 3 1 or 2 Family Dwelling-Number of Bedrooms 'Y Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use rft-r SPIQm*s <br /> ❑State Owned-Describe Use ❑City_❑Village Drfownship of..{naksaus <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' thew System y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> R. ❑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 S stem: Check all that apply) <br /> ,M 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.Di s ersaVi'reatmeat Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> 9A• 7 <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> NewExisting <br /> Tucks Tanks <br /> Septic or Holding Tank /0,,, <br /> Aerobic TreatmentUnit <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 /> R/c/c he le, es L .Q� �-- J{Sys/ pis- �Gb- vis) <br /> Plumber's Address(St eel,City,State,Zip Code) <br /> ,o 77d o 1/ 3s wa6sfr � u�Z sy�9? <br /> VIU.Coun /De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing t Signatu o Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial J�� 1(J . 12 p(s <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not Ins Man 81/2 x 11 inches in tie <br /> SBD-6398 (R. 01/03) <br />