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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit'Number(to be filled in by Co.) r <br /> De artment of Commerce (608)266-3151 4. <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 051q <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information .�.� 5,,IV Pf f v /� 1 I�t�r <br /> �-1� <br /> Property Owner's Name Parcel# Lot# Block# <br /> /rI i k °e 4,,,/ A 3 <br /> Property Owner's Mailing Address Property Location <br /> S7Q �-fi � ova.c�r <br /> 7/ <br /> Cl State Zip Code Phone Number �0 1A Section �b <br /> /;,, nl s ror, y37 �CJ / (circle one <br /> II.Type of Build' (check all that apply) T>�l N; R a E o <br /> �Zl pr 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Usecsyytr 4 011 4 <br /> ❑State Owned-Describe Use ❑City ❑villa e ownship of <br /> e.T© t �_) e r <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1p New S stem ❑Replacement System y ep y ❑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 /> ❑Non-Pressurized hl-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 ❑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 /> SaoS- <br /> VI.Tank Info Capianksj�� <br /> Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gof Units Concrete Constructed Glass <br /> New <br /> Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit J <br /> Dosing Chamber C <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 /> -e— � � 9/ <br /> umber's Address(Street,City,State, ip Code) <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee tincludes Groundwater Date Issued Issuing t Sign: Stamps) <br /> Surcharge Fee) ,L <br /> ❑ Owner Given Reason for Denial <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 11 inches in size <br /> SBD-6398 (R. 01/03) <br />