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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 84'e rli f <br /> ` I sc /�/I■ Madison,WI 53707—7162 Sanitary Permit Number(to be tilled in by Co.) <br /> Department of Commerce (608)266-3151 445&5,5 _tq 33;� <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Cotrim 83.21,Wis.Adm.Code,personal information you provide <br /> maybe used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) 00 <br /> L Application Information-Please Print All Information U,1 <br /> Greta Trz.l � od <br /> Property Owner's Name Parcel# Lot#0SSI -J, Block# <br /> Tom HowAi-X 1,IA- Rail It, -s o0 <br /> Property Owner's Mailing Address Property Location <br /> 6991 /S.A St, P/ace �✓ SE <br /> City,State Zip Code Phone Number -yti N6 �• Section A a / <br /> 0 14 k da I-e-. PnIV. SSI�.g (aSl-• 739- $4!S' circle one) <br /> II.Type of Building(check all that apply) T�6 N; R / E o® <br /> 1 or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> rA1954 tVV. <br /> 11 State Owned-Describe Use ❑Ce8Township <br /> of Jnoknan <br /> III.Type of Permit: (Check only one box on line A. Complete Bne B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> K Non-Pressurized 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 p El Other(explain) <br /> V-Dispersal/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Raw(gpdsf) Dispersal Arca Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> .3eo .7 1 4ta9 43d 9a. (a <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> NewExisting <br /> Tanks <br /> x <br /> Tanks <br /> pnc or Holding Tank Bop 9100 <br /> Aerobic Treatment Unit <br /> Dosing Clamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> R(�aL Nepk,.f 3- d,)tiS—S S"/ 7�S=6:44, �v— �f1� J <br /> Plumber's Address(Street,City,Stale,Zi Code) <br /> z,l 77(-0 Y wy, 3�` Websfer- wr .s`1�1 l5y3 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signs m o Stamps) <br /> Surcharge Fee) 1^G <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasone for Disapproval <br /> Attach complete plana(to the County only)for the system on paper not less than 81/2 x I I inches in slac <br /> SBD-6398 (R. 01/03) �(125 �Je-5t <br />