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Al Safety and Buildings Division County <br /> ■ 201 W.Washington Ave.,P.O.Box 7162 <br /> NVIsconsin Madison, ) 6-31553 707-7162 SanitaryPermit Nu ber(to be filled m by Co.) <br /> Department of Commerce (608)266-3151 -- 4-7892, - <br /> Sanitary <br /> I -7p <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> maybe used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> d a 8Z3 44RA <br /> Pro pe Owner's Name ( Parcel# Lot# Block# / <br /> Property Owner's Mailing Address c) , �"S 0 716 <br /> /1� ^ Property Location <br /> City,State / Zip Code u Phone Number y �y LJ v',NLJ��^, Section <br /> &i-Hu/ , � .T-9(f/d / � �- J u7_7 circle ot <br /> B.Type of Building(check all th::at apply) T-3 8 N; R L- E oo <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name �J CSM Number <br /> ❑Public/Commercial-Describe Use 1 ' .-_.�.. <br /> i <br /> ❑State Owned-Describe Use ❑City_❑Village PK-awn of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) 43`- <br /> A. <br /> New System ❑Replacement System ❑ 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 /> ANon-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.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �So , s` 9av o o 6.0 <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 Tanks <br /> Septic or Ht>it }'ank (7� 00 <br /> Aerobic Treatment Unit _ <br /> Dosing Chamber nv C� <br /> VII.Responsibility Statement-L 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 /> Plumber's Address(Street,City,State,Zif Code) <br /> VI I.Coun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui nt Signa o Stamps) <br /> Surcharge Fee) 1 <br /> ❑Owner Given Reason for Denial •J� ke ' <br /> IX.Conditions of ApprovaVReasons 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 />