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Safety and Buildings Division County <br /> 201` W.Washington Ave.,P.O.Box 7162 86'r-11 f'lt Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> isconsin (608)266-3151 <br /> Department of Commerce Stale Plan LD.Number <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,at 5.040)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information 1 5'ilwo 31rtk <br /> Property Owner's Name l Parcel# Lot# r3�7 ock# <br /> 011, 9{o Oa 08 -vin <br /> Ja sYl G6t 'n 4,e st✓ Prope yLocation <br /> Property Owntt's Mailing Address <br /> A7/7 /It3ed Ave- N15' _'/. _'/4, Section ald <br /> City,State Zip Cade Phone Number <br /> SS09Jr 763-H34- 97/•1 (circleoril ne <br /> E. $ettie( TQ N; RLE or <br /> II.Type of Building(check all that apply) 3 Subdivision Name CSM Number <br /> 91 or2Family Dwelling-NumberofBedrooms �IPIyP( 1r ' <br /> ❑Public/Commercial-Describe Use <br /> ❑City_❑Village XTownship of Jat.k 0 <br /> ❑State Owned-Describe Use <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 52Non <br /> New System ❑Replacement System ❑Treatment/Flolding Tank Replacement Only ❑ Other Modification to Existing System <br /> Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to NewListPreviousPermit Number and Date Issued <br /> fore Expiration Plumber Owner <br /> of POWTS S stem: Check all that a 1Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade [I 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.Dis ersal/freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(1; System Elevation <br /> �!S'O <br /> . 5- 643 X00 gyvl S 30 <br /> VI.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 Talcs , <br /> Septic.,Holding Talc 1000 <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 /> Rf4AK H&,Ak,o1 l�zl..r� 7/-f-- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 7 //w -? s r wt <br /> VI 1.Count /De artment Use Onl <br /> Sanitary Permit Fee(includes Groundwater Date Issued Is t Signam o Stamps) <br /> Approved ❑ Disapproved Surcharge Fee) C <br /> ❑Owner Given Reason for Denial 250 NP L-4 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not has Man ail x ti Inches in size <br /> SBD-6398 (R. 01/03) <br />