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Safety an Buildings Division County <br /> Visconsin <br /> 201 W.Washin on Ave.,P.O.Box 7162 Faso �"Madison WI 53707-7162 Sanitary Permit N bar(to be filled in by Co.) <br /> De artment of Commerce (6 8)266-3151 7,f 519 <br /> Sanitary Permit Application State Plan I.D.No ther <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal infinnir ation you provide <br /> may be used for secondary purposes Privacy Law,s15 04(I)(m) Project Address(if different than mailing address) <br /> 1. Application Information—Please Print All Information G�(e <br /> Property Owner's Name Parcel# Lot# Block# <br /> Lhtpne3 v Sctndt-w r)a.Gksovr <br /> Property Owner's Mailing Address Property Location <br /> 4{ 9'oS- ', bl Sr. <br /> City,State Zip Code Phone Number �E�A, 5k' �A, Section 3 3 <br /> W omrn i11N (circle <br /> T 39 N; R / Eoi <br /> II.Type of Bui ding(check ell that apply) <br /> 9 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> 13 State Owned—Describe Use ❑City_❑Village I ITownship of W. Ole rJh lam <br /> III.Type of Permit: (Check only one box on line A. Complete lin B if applicable) <br /> A. New System.� y ❑ Replacement System ❑Treatment/Hol ling Tank Replacem�n[Only 11 Other Modificati n to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of FEt Transfer to New List Previous Permi Number and Date Issued <br /> Before Expiration Plumber <br /> IV.Type of POWTS System: Check all that apply) <br /> zNon—Pressurized In-Ground ❑Mound>24 in,of suitable soil ❑N ound<24 in.of sui le soil ❑At-Grade ❑Sit gle Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Feet Filter ❑Aerol�ic Treatment Unit ❑Recircul iting Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pi ❑Other(explain) <br /> jes,g'n <br /> D'ssal/I'reatment Area Information: <br /> w(gpd) Design Soil Application Rate(gpdst) Dispersal A Required(st) Dispersal Area Proposed(sQ S stem Elevation <br /> a 7 �i 5 y3�Info Capacity in dTotalNumber Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons of Units Concrete Contra ted Glass <br /> ExistingTanks TsSeptic arHoldingTk <br /> Aerobic Treatment Unit OO <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibil'ty for installation of the POWTS shown on the attac led plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS No bar Busi s Phone Number <br /> Aie-k 110 kIn ��t rte. � /� J 1r8S'/ 7� �"6b - ell s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7-76 0 f/ 3s'" 6Ve6_</.e- w -s-Ys'?3 <br /> VIU.Count /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes roundwa r Date Issued Issui t Signs N Stamps) <br /> Surcharge Fee) 5C0� VI$q ,I <br /> ❑Owner Given Reason for Denial W /�70$ Mb II Q� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RWJ(610AJ — TMIOSF;E�L To (401005 Frb,- - os yoE2. oFi SP X8519 I <br /> Attach complete plans(to the County only)to,the system on paper not las than 812:11 inches fast. <br /> SBD-6398 (R. 01/03) <br />