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Safety and Buildings Division Count. <br /> ® 201 W.Washington Ave.,P.O.Box 7162 j�rG,Ai t- <br /> /� <br /> I SV vnsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co,) <br /> ,Department of Commerce (608)266-3151 7 3 <br /> Sanitary Permit Application Stffie Plan I.D.11Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide )) 3 3073 <br /> may be used for secondary purposes privacy taw,s15.04(1)(m) - Project Address(if different than mailing address) <br /> I. Appiicationinformation-PleasePrintAllInformation _E.J_ Zs—, �4�E os�/ r1. <br /> Property Owner'a Name <br /> / Parcel Loth Block-4 <br /> /1/�K e �cd 0'/Z e73 G 3 -0c'D . <br /> Property Owner's Mailing Address <br /> 657 9 8s'-s'II qvC �e ' Property Location <br /> city,Sam E <br /> Zip Code Phone Number — 14'A, Section %3G <br /> Ne cru Mu 5�37I �3 yyy -9ZW, p (shale <br /> IPL>Type of Building(check all that apply) TR��E o <br /> [tYl ort Family Dwelling-Number of Bedrooms 3 Subdivision Name 1 / CSMNumber <br /> ❑Public/Commercial-Describe Use �D 5 CSfn VI ao • a <br /> 11 State Owned-Describe Use ❑Ci ❑Villa e <br /> ry_ B e�'ownship0 D� �t! <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. News sjF <br /> YReplacement System ❑.TreetmentMolding Tank Replacement Only ❑Other Modification to Existing SystemB• ❑Permit RPermit Revision ❑Change of ❑PermitTransfertoNew List Previous Permit Number and Date IssuedBefore ExpiPlumber <br /> Owner <br /> IV. <br /> :Xpe of POWTS S stem: Check all that a I <br /> ❑Non-Pressurized In-Ground ound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constmcted Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculatin g Synthetic Media Filter ❑Leaching Chamber 11e Drip Line ❑Gravel-less Pi <br /> V.Dis crsau 1'rcatment Area Information: P Other(explain) <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(st) Dispersal Area Proposed(so System Elevation <br /> TSS 1. 6 �sv �r� qg. -7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab <br /> Gallons Gallons Numbeof r Site Steel Fiber Plastic <br /> Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic rHolding Tele <br /> Aerobic Treatment Unit QOD 600 �?U r .q <br /> 7 <br /> using Cha VgESC! i)/!o <br /> t,00 ban <br /> VI1.Responsibility Statement- 1,the undersigned,assume responsibility for Inst the POWTS shown on the attached plans. <br /> lumber's Name(Print) lumber's Signator M umber <br /> w� .r1 Business Phone Number <br /> P umber's Address([Street,City,State,Zip e) <br /> ,c.)(� i `'i IJ-0-0-7 �u c 15V Bra <br /> VI .Coon /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signature ps) <br /> Surcharge Fee) ''p , <br /> ❑Owner Given Reason for Denial 7 �,Z,SijQ OS <br /> IX.Conditions of ApprovaVRcasons for Disapproval <br /> Attach complete Pham(to the County only)for the system on paper not Im oum 91/1 a 11 inch.in size <br /> SBD-6398 (R. 01/03) <br />