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Sulcty and Building,Division County Il <br /> ` 201 W.Washington Ave.,P.O. Box 7162 T/ -_ <br /> iseonsin Mattison, W1 53707-7162 Sanitary Permit Number(lo be filled in by Co) <br /> Department of Commerce (608)266-3151 <br /> Shue flan I .Number <br /> Sanitary Permit Application <br /> Ili accord with Comm 83 21,Wis,Adm.Code,personal inflmnntion pm provide <br /> may be used for secondary purposes PriwwN I.aw.s 15 04(1)(m) Project Address(it dilferenl than mailing address) <br /> 1. Application Information-Please Print All Information <br /> 0 �. <br /> Prop y Owner's NamC�. <br /> llam�q e Parcel k Lr oq6 Qe Block# <br /> ) <br /> r <br /> Properly Owner's Ma' mg Address Property Location /n C- <br /> J <br /> ,15- ¢ • 4J A,A) '/.. Section, l� <br /> City.State Zip Code Phone Number <br /> Aj 5 r�[/�. / I�1 -yoCi circle one) <br /> •` .J Z l� (9 ._ /_. f 0 N; 12G 1,r® <br /> 11.Type of Building(check all that apply) <br /> AIor2lvmily Dwelling-Number ol'HcdSubdivision Name esu'N +1ler <br /> ronms <br /> DPublic/Commercial-Describe U,e C �Tnn in cjc/'T'0 <br /> 1 <br /> DState Owned-Describe Use OCity_OVillage Wawa ship <br /> G _ <br /> III.'rype of Permit: (Check only one box on line A. Complete line B inapplicable) <br /> Jew System D Replacement System D Treminent/l lolding'I'ank Replacement Oil Iv D Other Modification to Existing System <br /> B. D Permit Renewal D Permit Revision D Change of D Pei not'frmsler to Ncsc List Previous Permit Number and Dale Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> —"- - <br /> Noil-Pressurized In-Ground G Mound>2J in.ofsouable sad ❑ Mound<24 iu of suitable sml 11 Al-Grade D Single Pass Sand Piller <br /> Constructed Wetland D Pressurized In-Ground r1 I loldnig'I'ank D Peat Filter D AereblC"I teal nent Unit D Recirculating Sand Pilfer D <br /> Recirculating Synthetic Media Filter U Leaching Chamber U Drip Line U Grarcl-less four. LI Other(explain) <br /> V. Dis ersal freatment Area Information: ---- <br /> Design Flow(gpd) Design Soil Application Rate(gpdsO Dispowl Arca Required(sl) Dispersal Ana Proposed(sl) System Elevation -- <br /> yS� -7 6y iso �, 5 <br /> Vl.Tank Info Capacity in Towl Nnlllher Mo..ufucturrtr Prefab Site Stccl fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Ghis's <br /> Ncw L"'1,, <br /> "rn��ks Tanks <br /> scull,or l kadj,*t Ti ak 00 — DUD SKrr► �✓ <br /> Aerobic Treatment(hill <br /> Dosing Chamber <br /> VI 1.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the PONNTS shown on the attached plans. _ <br /> ]'lumber's Name(Pr m) I'lumber's Signature MP/MFRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VI .Caun v/De artment Use Only _ <br /> proved D Disapproved Sanilap fern,it i'ee(includes Cruundw;ner Dat,Issued Issuing(q/Yenl Signature(No Stamps) <br /> Surch;ugc fcc) ��y� ��7x�f1C9 tMp,� "�3�.. <br /> D Owner Given locus....for Denial <br /> IR.Conditions of Approval/Idcasons for Disapproval <br /> Am,ch comp@tc plans(lo the Cumonry 111,1))for[hr Mon.on paper not Icss than 81/2 s 11 inches in.vies -.— <br /> SBD-6398 (R. 01/03) <br />