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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 4 1 <br /> 16sconsin MadisOD,W1 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 • -7 F) Ski / n� <br /> Department of Commerce `J-1 <br /> Sanitary Permit Application State Plan I.D.Number Q <br /> In accord with Comm 93.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(I Xm) Project Address(if different than mailing ress)add <br /> I. Application Information-Please Print All Information 03(o_ <br /> Property ra.,ner's Name J Pared# Lot# Block# <br /> 1DA& mnu—T 2 <br /> Property Owner's Mailing Address Property Location <br /> FV-D ROM-Eq COAD Null,,, (Ory., Section ,s <br /> city, <br /> ``Suite <br /> ,, ``''-- •�l C Zip <br /> ACodde Phone Number �l <br /> J�rV)I� /VIIV S�1`13�) -7�5 -265- 725� Ao '�cirole <br /> T N; R ! E <br /> II.Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> Ael or 2 Family Dwelling-Number of Bedrooms . Wt37gq va Zi PG 37 <br /> ❑PubhcACommercial-Describe Use ❑ e <br /> ❑State Owned-Describe Use City ❑Villageownship of l��(�I V <br /> HL Type of Permit: (Check only one box or line A. Complete line B if applicable) <br /> A' flew System ❑Replacement System ❑Treaiment/Hohiing Tank Replacement Only ❑Otho Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Cham of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System Cheek all that appW <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 Welland ❑Pressurized ton-Ground ❑Holding Tank ❑Peat Falter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) . <br /> V.Dis aVfreatmeat Area Information: <br /> DesiFlow(gpd) Design Sal Application Rate(gpdsf) Dispersal Arra Required(so I}ispersal.Area P�ojles�l(g9,� System Elevation <br /> 5 . 7 1047 ;dAl <br /> 1e1N�s,u <br /> VL Tank Info Capacity in Total Number J Manufacturer Prefab Site L Steel Fiber l�Plastic <br /> Gallons Ganong of Units Concrete Constructed Glass <br /> New Eidstm <br /> Tashi Tams , yam L Dy� <br /> SepticorHoldmg Talc `f�M. IW J j U <br /> Aerobic Trete Unit /U1J <br /> Doig Chusbar <br /> VIL Responsibility Statement-1,the undersigned,assume respo bility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) r Business Phone Number <br /> �f"Er F rax PI s1 '7�1�4z 7�5 —755—Z9�l <br /> Pl=Ws,Address(Street,City,State,Zip Code) (j <br /> 1 , {�Q(), Bc6c JJ� � 1=1� r VV/ \oo t4 <br /> - <br /> V)II.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued711L, <br /> aa Si o Stamps) <br /> Approved ❑Owner Given Reason for Denial 3rardrarge Fee) /F�CD.f7 <br /> )7L Conditions of Approval/Reasons for Disapproval7 <br /> !y (J Y <br /> Amen nmpleh Mer(to ala Cab■4 60110 ser ue 101110111100 paper Not teas arm stn:ti beta re a'ee <br /> SBD-6398 (R. 01/03) <br />