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ON COMPUTER/SCANNED <br /> Offay <br /> Safety and Buildings Division C <br /> ` Isconsin 201 W wffihtngton Ave.,P.O.Box 7162 ��r Ne,{�- <br /> Madisoq W1 53707-7162 <br /> De artment of Commerce (608)266-3151 Sanitary Permit Number(to be filled in by Co.) <br /> SanitaryPermit A S3z 1 & 7 <br /> Application Stale Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm,Code,personal information // ,/� <br /> may be used for seconds �, you provide OVA-6 IrCVI VW Uj <br /> secondary Purposes Privacy Law,s15.04(I)(m) Project Address(it ditferent than mailing address) ( \ <br /> I. Application Information-Please print All Information yy �1 <br /> Property Owner's Name 1176- are <br /> keG P—# Lot# Block# <br /> Property Owner's Malting Address �/l• - -�� <br /> Z ! Prope ty Location <br /> Ciry,State (4TL <br /> Zip Code Phone Number --yt __Y, Section <br /> N ur V► 0SW /72,<IL Type of Buildin check all that apply) }�j/,,s� arcle gore) <br /> �g T_1QN; R�Eof J <br /> gs10R Family Dwelling-Number of Bedrooms Z 1� <br /> Subdivision Name CSM Number <br /> ❑PublidCommemial-Describe Use <br /> ❑State Owned-Describe Use <br /> ❑City_❑Village Wrownship of9993 <br /> fie/ eA- <br /> 111.Type of Permit: (Check only one hos on lice A. Complete floe B if <br /> A. applkahle) - a _ _ <br /> ❑New System [Replacement System 13T _I .3",r- .S-00 <br /> b <br /> rutmenNliolding Trek ReplacementONy ❑Other Modification to Existing System <br /> IL ❑Permit Renewal <br /> ❑Permit Revision ❑Change of ❑permit Transfer w New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber <br /> Owner <br /> I V.T of POWTS S stem: Check all that a 1 <br /> ❑Non-Pressurizcd Ire-Ground ❑ Mound>24 in.of suitable soil ❑Mound<24 in,of suitable soil ❑At-Grade 11 Single Pass Sand Filter <br /> Constructed Wetland El Pressurized In-Ground Rr Holding Tank ❑Peat Fikwr ❑ <br /> Recirculating Synthetic Media Filter ❑Aerdac Tn'atarrent unit ❑Recirculating Sand Filler ❑ <br /> V.Dis erind/Treatment Ares Information-mon ❑ I�rre ❑Ca°vel-lesaPipe El Other(explain) <br /> Design Flow(gpd) Design Soil Application Ra <br /> 1dPdst)gD sprsai Area Required(sf) <br /> 300 Dupdml Area <br /> lioposed(st) System Elevation <br /> VL Tank Info Capacity in Total Num taa <br /> Manutanurer Prefab Sire <br /> Steel Fiber Plastic <br /> Gallons Gallons of Units <br /> Now F.:..:ag Concrete Constructed Glass <br /> T'rkz Tendo <br /> Septic or Holding Tank 1 <br /> Aerobic Tres[,,Ural L <br /> Dosing Ciombrr <br /> VII.Responsibility Statement-h the sederaigoed,aasarx <br /> PI 's N^(Print) PI 's Signatu IRy ler iaraWtlea of the POWTS shown OR me attached plans <br /> 10 kk�r MPIIMPRS Number Business Phone Number <br /> Plumber's Address(Street,Ciry,State,Zip Cade JW-ma 7b <br /> Z o 3 M.,es--. wd er <br /> VIII.Coun /De artment Use On <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Gronrdwater qte Issued Iswin <br /> SU-Cbwge Fee) 7 ` t Signatu (N tamps) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions ofApprovaVReallows for Disapproval <br /> Sem AkAJ An1 ,, � 3�l�t�O �o� 47u <br /> Amro comtaeh pbm(lo me Casty aYy)ter 14 a <br /> ysb u fryer ar rrss Wa a12:I/loch in sire <br /> SBD-6398 (R. 01/03) <br />