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Safety and Buildings Division County /fir!/ <br /> /� <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> VVisconsin Madam,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (60266-3151 551208 <br /> Sanitary Permit Application State Plan I. Number 1 1 S <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide r/ k (11�t,J <br /> may be used for secondary purposes Privacy Law,sl5.04(IXm) Projm'rAddress(if different than mailing address) �l <br /> 1. Application Information-Please Print AB Information Y 5o 3 <br /> Prnpef Dj D °2.2 0*l5 2wner's Name Parce!I 71 15 t5-/55-oni� <br /> Property Owner's Ma iling Address Property Location <br /> g_ianz- fiqcik At )z/ z 7 <br /> S(, Sf,Secuon <br /> City, 1Syt�arte /J /V/\/ <br /> �_ / Zip Code �/ Phone Number s�- <br /> `'IFC Ci6 /'// ��L `/2�/ZZ d✓ °trete one) <br /> T �0 N; R ! ✓ EorW <br /> II. Type of Building(check all that apply) <br /> phLp'I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> LJ Public/Commercial-Describe Use CAGG65 �i IkPDOVA) //t--o--(/.V. <br /> ❑State Owned-Describe Use ❑City_❑Village Ptownship of �LWN <br /> Ill.Type of Permit: (Checkonly one box on line A. Complete lice R if applicable) <br /> A" ❑ New System 1q Replacemeru system ❑TreamseralHomung Tank i <br /> / Replacement Only ❑ Odrr Modification to Existing System <br /> B. El Permit Renewal ❑ Permit Revision <br /> ❑ Charge of ❑Permit Transfer in New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber 001111:17 <br /> IV.Type of POWTS System: (Check a6 that ) <br /> Non-Pressurized In Ground ❑ Mound > 24 in.of suitable will ❑ 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 Litt ❑Gravd-fess Pipe ❑Odicr(captain) <br /> V.Dispersalfrreatment Area Information: <br /> Design (gpd) Design Soil Application RaWgpdct) Dispesspal Ara Required(s0 Dispersal�tArra Pro <br /> /Od 9 posed(s0 SystemO Elevation <br /> VI. Tank Info Capeciry in Tool Number Manufscertcr Prefab Site P !Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New TF-xMng <br /> Tanks Tanks <br /> Septic or Hokting Tank Iwo 1000 / <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume respoosilaMy fa bustaBNiao of the POWTS shown on the attached plans. <br /> 71011"' <br /> lu 's Nuri t) / 's Signa MPIMPRS Number Business Phone Number <br /> o /014 /wz_91" 85/gS�/ 7fS666�o <br /> Plumber's Address(Street ,City,State,Z") <br /> 277,26 �3h►r�^� // tAte&Av' lel.%A <br /> VIU. County/Departinent Use Only <br /> Approved ❑ Disapproved �mtwy Perrmt Fee(includes Groundwater Date Issued Issw Signatur o Stamps) <br /> ❑ Owner Given Reason W Denial SlrtdWgc Fix) N tae <br /> IX. Conditions of Approval/Reaswrs for Disapproval �l(/ <br /> Attach complete tins(w the County ody)for the sysa m as papv wt few than M12 x 11 inches in site <br /> SBD-6398 (R. 01/03) <br />