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Safety and Buildings Division County _--' <br /> —/--- 201 W. Washington Ave.,P.O.Box 7162 -� <br /> `�SVOnSIn Madison, WI 53707-7162 1tYH —by <br /> _____ <br /> Sanitary Permit Number(� to be filled in byCo) <br /> Department of Commerce (608)266-3 15 1 x(-78 595 <br /> -- <br /> Sanitary Permit Application State Plan I D Number-- <br /> In <br /> umber —In accord with Comm 83 21,Wis.Adm.Code,personal information you provide <br /> maybe used for secondary purposes Privacy Law,s15.04(I)(m) Project Address(ifi ifFerent than mailing address) <br /> 761a�--L Application Informs[ion-Please Print All Information � �1y <br /> Property Owner's Name 1-6' /a k '` T)I- <br /> G, <br /> - <br /> N l.ol N Block q <br /> � kY tS �� ©�6 �tE �D3 <br /> Property Own 's Mailing Address Property Location <br /> a �1ss �a it de, , y�.p/� <br /> CIL),State Zip Code Phone Number q• AW,' Section <br /> I <br /> 7i1- 8(06- �D // (circleo�) . <br /> ii..'Type of Buil ing(check all that apply) T N; R[�E or <br /> V1 or 2 Family Dwelling-NumberofBedrooms__ Subdivyiysiion'N/amee] CSM Number <br /> Public/Commercial-Describe Use <br /> State Owned-Describe Use ❑City_1JVillage/KTownship of (C��rKd <br /> ` Ill Type of Permit• (Check only one box on line A. Complete line B if applicable) ---- --'--- <br /> 4 r __ <br /> New System ❑ Re lacemenl S stem <br /> r- III P y 1.1 TreatmenVHolding Tank Replacement Only ❑ Other Modification to Existing System <br /> B- l_- Pertnd RenewalTD Permit Revision <br /> ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> Y !V <br /> IIV.'ly_pe of POWTS System: (Check all that apply) --_-_-- <br /> I <br /> X� Non -Pressurized In-Ground ❑ Mound>24 inof suitable soil Ll Mound<24 in.of suitable soil 11At-Grade 11 Single Pass Sand Filter <br /> Cuns[mcted Wetland (J Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter L <br /> Ren,r, !I Eng Synthetic Media Filter ❑Leachin Chamber ❑Dri Line <br /> g p ❑Gravel-less pc Pr]Other(explain) _ <br /> V.Dt�ersal/Treatment Area Information: _ --- <br /> rDesign Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> __I <br /> I VL'Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Cxisting <br /> Tanks Tanks <br /> Septic Hold.gTim, _I <br /> 000 LcJ/tS[✓ <br /> Aerobic Treatinem Ur,ir <br /> Dos,n­8 Chsmber �- <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name Pro PI nher's Signa re 11 1PR5 Number Business Phone Number <br /> QCs �ae• r' ay, zzSLzy <br /> Plumbers Address(Sneer,Ci ip Code) , — I — --- <br /> Vlll.Coun /De artment Use Onl <br /> r' Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued lssuin g ignature ps) <br /> Surcharge Fee) /�❑ /'�,eA {�Owner Given Reason for Denial 25V i /V <br /> IX.Conditions of Approval/Reasans for Disapproval <br /> Attach complete plain(ta the County an,y)for the system on paper not leas than 812 x 11 iacha in aim -' <br /> SBD-6398 (R. 01/03) <br />