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ildings Division County <br /> ?Depla <br /> m F;;M(608) <br /> Ave.,P.O.Box 7162seonsin 53707—7162 Sanitary Permit Nu ber(to be filled in by Co.)tment of Commerce 66-3151 "ATf(�D _e6 U <br /> Sanitary Permit Application Stam Plan I.D.Number <br /> in accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s I5.04(1)(m) <br /> Project Address(if different than mailing address) <br /> L Application Information-Please Print AB Information <br /> Property Owner's Name <br /> ams, <br /> Parcel# Lot# Block# <br /> �eMef ���, o� - <br /> Propery Owner's ailing Address <br /> Property Location <br /> f37�// tThnton Sr: /t/E <br /> City,State Zip Code Phone Number —�A� _YS Section-�,7 <br /> IFRa Z/< *" /. SS3o9 ((arcleo <br /> II.Type of Building(check all that apply) T_�N; R 15 E oe0 <br /> ®1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> 11Public/Commercial-Describe Use -1 I /1 / <br /> 11 State Owned-Describe Use ❑City_❑Village.ffTownshipof✓ave-/CVs,rl <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. rL New System Y El 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 <br /> Permit Number and Date Issued <br /> Before Expiration Plumber Owna <br /> IV.T of POWTS S stem: Check all that a I <br /> Non-Pressurized H-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in,of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑Pressurized hi-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter []Leaching Chamber ❑Drip Line ❑Gael-less Pi e <br /> V.Dig ersanreatment Area Information: P ❑Other(explain) <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(st) <br /> oO 5" System Elevation <br /> 6OO <br /> 3 <br /> bap 9i.o /90.p <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab <br /> Gallons Gallons of Units Site Steel Fiber Plastic <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Dalt <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume respon <br /> Plumber's Ne aibitity for Installation of the POWTS shown or the attached plans.am (Print) Plumber's Signature MP/MPRS Number <br /> Business Phone Number <br /> Plumber's Address(Street,Ciry,State,Zip <br /> .� 7?°o yN.y 3s we6sf�. w1 S9P93 <br /> VIII omit /De rtment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing an gram tamps) <br /> Surcharge Fee) 25 `1" 10 <br /> 101Owner Given Reason for Denial (/(0U <br /> IX.Conditions of ApprovttUReaaona for Disapproval <br /> OCT 2004 <br /> SURNE7T COU <br /> Athcb tompleta plum(to[he County only)(or[Fre system on paper oo[las than BIR x[I lucha In sire O NTy <br /> SBD-6398 (R. 01/03) <br />