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Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 .)W 6Tr <br /> Madison,W1 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> isconsin <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application Sate Plan .D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> maybe used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information LAS/ O <br /> Property Owner's Name Parcel# Lot# Block# Cr <br /> P#Ic� 1 iomup ey Ory- 3130- 01-&v0 <br /> Property Owner's Mailing Address ��/"-7"� Property <br /> Location <br /> P, V- \(r 7 / / / /., /"'�'/., Section <br /> City,State Zip Code Phh.ne Number ) <br /> aON30 <br /> � q 91fS/� ��pp /(i(circleo <br /> 11.Type of Building check all that apply) <br /> TQ_L N; Rl E W <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use__ <br /> ❑State Owned-Describe Use u ❑City_❑village X—ship of k <br /> III.Type of Per <br /> (Check only one box on line A. Complete line B if applicable) <br /> A. ew System y El Replace System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit 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 /> on-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 ❑Gravel4ess Pipe El Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Vl.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> NewExisting <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VIL Responsibility Statement- 1,the under some responsibllity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) er's Signature <br /> Pl MP/h4PB6Number Business Phone Number <br /> clw ICIV4.&Y i (a2 43V-3997 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Owco R� hHQLkWap W7E SVPV? <br /> VIIL County/Department Use Ord <br /> EW/Appr ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui gent �gna o Stamps) <br /> Surcharge Fee) ��,t/) <br /> ❑Owner Given Reason�Dm.l <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x I l inches in size <br /> SBD-6398 (R. 01/03) <br />