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Safety and Buildings Division County L <br /> 201 W.Washington Ave.,P.O.Box 7162 V rov <br /> Madison,W1 53707—7162 Sanitary Permit Number(to be filled in by Co) <br /> Vi'sconsin '486,645(608)266-3151 '4S6,6 4 j <br /> Department of Commerce State Plan I.D.Number <br /> Sanitary Permit Application —tr <br /> In accord with Comm 83 21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if ch than mailing address) <br /> 1. Application Information—Please Print All Information /'z 4 2 <br /> Property Owner's Name Parcel N Lot# Block q <br /> (.IVt <br /> 3a 020, -vz <br /> Property Owner s Mailing Address Property Location C-61/4-- <br /> 6 <br /> /4-- <br /> 6f` _y., Y., Section <br /> City,State Zip Code Phone Number <br /> iri 'n o , Iv 56 Y36 /��� circle ) <br /> T_W N; RAI oIt <br /> It.Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> �91 or 2 Family Dwelling—Number of Bedrooms <br /> ❑Public/Commercial—Describe Use <br /> ❑City_❑Village 71iownship of <br /> ❑State Owned—Describe Use <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> ❑ Chan List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal El Permit Revision Change of El Transfer to New <br /> Before Expiration Plumber Owner <br /> IV.T e of POWTS S stem: Check all that a I <br /> )CNon 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.Dis ersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> . 7 6y d y 99-zs- <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 0/V IQ <br /> Aerobic Treamnent Unit VW <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI tier's Name(Print) / PI er'sSinature MP/MPRS Number Business Phone Number <br /> O�� nil r r S��$L/ 6 9070 <br /> Plumber's Address(Street,City,State,Zip C <br /> 27220 136N Wei, k 4 <br /> VIII.Count /De artment Use 0 <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing A ignature(No s <br /> Approved ❑ Disapproved Surcharge Fee) .Mt �f 10L11 <br /> 07 ` <br /> ❑Owner Given Reason for Denial JP / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Atmch complete plans(to the County only)for the system on paper not lag than 81R x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />