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Safety and Buildings Division County <br /> NVisconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 U,rnf,Madison,W1 53707—7162 Sanitary Pennit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 445 (F 90 µ S <br /> Sanitary Permit Application State Plan I.D.Number tf <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s 15.04(1)(in) Project Address(if different than mailing address) <br /> I. ApplicationInformation—Please Print All Information LTO gi A&/k- SSf 1 <br /> Property Owner's Name Parcel# Lot# Block# <br /> 0;6 —9%AOO --tO70O w <br /> Property Owner's Mailing Address Property Location V1 <br /> 60/ GIrbre n /*mv sure 630 Nut <br /> City,State Zip Code Phone Number 1/., s� '�•, Section <br /> MInr tG ori ki%_ 1,4 N SS"34S' (circle ) <br /> �6 <br /> Ilf.Type of Building(check all that apply) T " N; R E orLW <br /> ,mI or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village&Township of 0,4k10tn <br /> 111.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. <br /> ❑ New System .Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B• ❑ Permit Renewal ElPermit Revision El 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 app 1 <br /> XNon-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 ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 3 oD . S� 4e'y q 3 d- sy. :r-- <br /> V1.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,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 /> �(C_k o /cin S ,:.,.= <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 774 0 fr`,. �S` r�e�s�`�✓ r,✓� S��s 3 <br /> Vlll.Count /De artment Use Only <br /> Approved ❑ Disapproved 7Sanitaryermit Fee(includes Groundwater Date Issued Issuing a ignature Fee) <br /> ❑ Owner Given Reason for Denial �•V//� 9 �3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/3 x 11 inches in siu <br /> SBD-6398 (R. 01/03) <br />