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Safety and Buildings Division CountyO <br /> 201 W.Washington Ave.,P.O.Box 7162 34,.a-rt 1 <br /> Vi�scqnsin Madison, ) 6-315 53707-7162 Sani ary t Number(to be filled in by Co.) <br /> Department of Commerce (608)266-31St r� <br /> Sanitary Permit Application State Plan I.D.Numb <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> maybe used for secondary purposes Privacy Law,sI 5.04(1)(m) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Information 2 <br /> Property Owner's Name Parcel# Lot# ,'� Block# <br /> Kev%rt I3/ul,.n V-17 R66 oL.-- Yr/Y—od/?D <br /> Property Oumer's Mailing Address Property Location <br /> /ra It &ov Lo1- <br /> P.n e Rr� e Dr r V Zip <br /> /, _/, Section /7 <br /> City,State Zip Code Phone Number <br /> tr°a, [d 015Wr .TYOd� -1r3dS (oral -8141 :4rr) r (circle o ) <br /> 11.Type of Building(check all that apply) p T mon R y E or <br /> ID <br /> ®I or 2 Family Dwelling-Number of Bedrooms ✓ Subdivision Name CSM Number <br /> ❑Public/Commereial-Describe Use <br /> El State Owned-Describe Use ❑City_❑Village RTownship of sfo?'I'' <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑ TreatmenHoldingReplacement Only El Other Modification to Existing System <br /> B. ❑ 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 System: Check all that apply) <br /> 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 Cl <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis emaVFreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> yso S Soo 900 1 9 el 90 <br /> VI.Tank Info Capacity in Total HUnitm <br /> Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /000 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- t,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> Ple-k f7a kfofJ os/�sd� Of�SBS/ 7rs-�66 - > <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ot7760 Hw �s w sfe.� wSsYSs <br /> VIII.County/Department Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing en Signature o mps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial yP J (G <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the splem on paper not less than R12 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />