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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> %pisconsin Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 476 1'34 <br /> ,. Sanitary Permit Application State Pl Ann I.D.Number y <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide N)R rorr reg"" <br /> v(- CaLS <br /> may be used for secondary purposes Privacy law,s I S 04(l)(m) Project Address(if diffinent then mailing address) <br /> I. Application Information—Please Print All Information n0� M I_ 32 7 01Wt"y 700 <br /> Property Owner's Name (, IrJ Parcel# Lot# Blmk# <br /> Property Owner's Mailing Addfcs§ Properly Location <br /> 3 sc A, Akj v., section � <br /> City,State Zipp C�odd/e� Phone Number <br /> /d /b4 X26 T30 N, R/IL(circlene) <br /> 11.Type of Building(check all that apply) —F "tet^ <br /> KI or 2 Family Dwelling-Number of Bedrooms 2- Subdivision Nome CSM Number <br /> Public/Commercial-Describe Use LO. <br /> ❑State Owned-Describe Use ❑City_❑village Pfownship of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System E?Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑ Permit Revision 11 Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber (honer 2 Grr 1 <br /> Type of POWTS System: (Check all that apply) �J <br /> Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑Single Pass,and 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 ersaVTreatment Area Information: <br /> Design Flow( Design Soil Application Rate(gpdst) Dipersal Arca Required(sf) Dispersal Area Proposed 1: System Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer IPrefab Site Steel Fiber Plastic <br /> i. Gallons Gallons of Units Concrete Constructed Glass <br /> New Fvdsting <br /> T..•ks Tanks <br /> Septic or Holding Tank -- - — — <br /> Aerebie Trmromnt Unit / klf <br /> Dosing Chamber -- <br /> VII.Responsibility Statement- 1,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 /> 5--f72-y1a <br /> Plumber'sAddmss(Street,City,State,Zip Code) <br /> V111.Coun /De artment Use Only _ <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Dale Issued Into t Sign Stamps) <br /> Surcharge Fee) �\ <br /> El Owner Given Reason for Denial U'� b5 <br /> ti <br /> LX.Conditions of ApprovaVReasons for Disapproval <br /> Sl�Sfe„T /5 Rc'SrOmJTIM WITW paAa762'S oFFlc6arrFJl41 46146. <br /> 5rhrts P4W -App wv- 6 Nor Reu1R6o. <br /> Anacb complete plain(in be County only)for the system on paper not lees than 812 x Il inches iv mitt <br /> SBD-6398 (R. 01/03) <br /> crslra��r 1 I i r---- <br />