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Safety and Buildings Division Count <br /> m 1 201 W. Washington Ave.,P.O.Box 7162 y <br /> � Iscvns Madison,WI 53707— 43«r n e 1 f <br /> in 7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)2b6-3151 <br /> Sanitary Permit Application +9 399 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide State Plan I.D.Number <br /> may be used for secondary purposes Privacy Law,SI 5.04(i)(m) 133 15.? <br /> L Application Information-Please Print All Information //,^, Proje-t uio ass it,ainerent than mailing address) <br /> Property Owner's Name 3�7�W II De v.tS 4K A <br /> /11,11r14 It, k/r Parcel# Lot# DZ- Block# <br /> SfCn ,/Rrr/SOr� <br /> Property Owner's Mailing Address O}O - Q31-C" o3 7/0 <br /> 13 .1 3d f y /Jv e N Property Location/ <br /> City,State 60 V'L.(427 7 <br /> Zip Code Phone Number �, __V, Section 3r w+safk ,rrN SS 4y f <br /> 11.Type of Buildin check all that a I 76 3-SS7- („$3q YO <br /> T /((Eorecircle one) <br /> 4( PP <br /> QIor2 Family Dwelling-Number of Bedrooms 3 N R &, <br /> ❑Public/Commercial-Describe Use CS V. CSM Number <br /> ❑State Owned-Describe Use `—'m V I <br /> If I.Type of Permit: (Check only one boz on line A. Complete line B if applicable) ❑City-❑Village XTownship of OAK/Ano( <br /> A. <br /> ®New System ❑Replacements stem <br /> Y ❑Trea[ment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal <br /> ❑Permit Revision ❑Change of List Previous Permit Number and Date Issued <br /> Before Expiration B El Transfer to New <br /> Plumber Owner ��//-- <br /> IV.T e of POWTS S stem: Check all that e 1 '- 1__ �, �JD� <br /> ❑Non-Pressurized In-Ground ®Mound>24 inof suitable soil ❑Mound< <br /> Constructed Wetland 24 in.of suitable soil ❑At-Grade EJ Single Pass Sand Filler <br /> ❑Pressurized In-Ground EJ Holding Tank ❑peat Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> V.Dis ersal/1'reumen[Area lnfor❑ma[ion1ng Chamber ❑Drip Line ❑Gravel-less Pi <br /> Pipe ❑Other(explain) <br /> Design Flow(gpd) Design Soil Application Ra <br /> te <br /> Ln Flo (BPdst) Dispersal Area Required(St) Dispersal Area Proposed(sf) System Elevation <br /> Vl.Tank Info Capacity in 9 Total Number �s'SD SOO <br /> Gallons Gallons of Units Manufacturer Prefab <br /> Site Steel Fiber Plastic <br /> New Ta,Eoietffig <br /> Septic or Holding Te,dc Tanks Tanks Concrete Constructed Glass <br /> /oep isao <br /> Aerobic Treatment Uni[ <br /> Dosing Chamber <br /> 600 600 <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) <br /> I� <br /> Plumber's Signature fGIL // MP/A4PRS Number <br /> f/e /<,,,s !T Business Phone Number <br /> Plumber's Address Wilevii,City,State,Zip Code) aAt�'f� 7/S—�6 6 - V/.S'-7 <br /> ) 7'76o f/.,. 3.f WefllftI GriT <br /> VIII.Count /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater <br /> Surcharge Fee) Dale Issued Issuin <br /> ❑Owner Given Reason for Denial b 2 vv✓J' g ignatur o Stamps) <br /> IX.Conditions of App rovaUReasons for Disapproval °P cJ /0 j'6 6 <br /> see �o 2f32si9 Fon. ov15IWAf Sotl �rtGutTrh), �Ci <br /> Athch complete plater(to the County only)for the system on paper not less than 81lt x II ioehee in size <br /> SBD-6398 (R. 0]/03) <br />