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Safety and Buildings Division County <br /> ` ar 201 W.Washington Ave.,P.O.Box 7162 8"rq C 1Y— <br /> �sconMadison,W153707-7162 Sant®ryPermitNumbcr(to befilled inbyCo) <br /> Department of Commerce (608)266-3151 452,53 <br /> Sanitary Permit Application gam ra LD Nnmbe' ` <br /> In accord with Comm 83 21,Wis.Adm.Code,personal infounalian you provide V V <br /> may Is,used for secondary purposes Privacy Law,s1504p)(m) Project Address(if different than mailing address) (1 <br /> L Appllevtion Information-Please Print All lnformatioa <br /> 3048'4 07yr;e1e Lk r? <br /> Properly Owner's Name Pamelp fat# Black# <br /> GA ICmalt w/l as{.t -r�fy_o/800 <br /> Property Owner's Mailing Address Property location <br /> 7193 N 01,1ee z e D.. <br /> Ciry,State Zip Code Phone Number Sestom a49 <br /> bar S4f3o 7.Y-Efri- TS7J T YI N; Rhex <br /> 11.Type of Badding(chock v11 that apply) <br /> ®lor2Family Dwelling-NumbmofBedrooms d Subdivision Name CSMNumber <br /> ❑Publtc/Bommacial-Describe Use_ <br /> ❑grate Owned-Describe Use ❑Ciry_❑V'llage twaships, l5 <br /> III.Type of Permit: (Check only one box on line A. Comptek line D if applicable) <br /> A_ ❑New System IR Replacmnenl System ❑TrewrmVHoldiug Tank Replacement Only ❑Other ModlBwtion to Exiating S,hwu <br /> B. ❑Permit Renewal ❑Permit Revision 11 Change of ❑Pa,mitTmmferto Ncw List Previous Permit Numberand Emelssued <br /> Bctor,Expintiau Plumber Owner <br /> IV.T eofpOWTSS ate.: Cheukallthvta I <br /> R Non-Pressurizes InGround ❑Mound?24 in.of suitable mil ❑Mauml124 in.ofsuiahle sail ❑AFGrade ❑Single Pass Sand Film, ❑ <br /> Constmcted Welland ❑PressurizW N-Ground ❑Nolleg'1'ank 11 Pent Film' ❑Aembichamossm Unit ❑Reinumlating SadFiller ❑ <br /> Recounlalin Synthetic Media Filter ❑Leaching Ch,m,,, ❑Dripline ❑Gravel-less Pipe ❑Other(ex Iain) <br /> V,Dis rsal/Freatment Armli, 'are tion: <br /> Desks,Flow(gpd) Design Soil Application Rate pdaf) Diapm.1 Area Required(at) Dispersal Arco Proposed(no System Elevation <br /> 300 , -s`- 600 <br /> 600 9i r <br /> VL innk Info Capacity Numbv Manufacwm Pmab Site St¢I <br /> GFiber Plastic <br /> (cellons Galloelle ns of Unice Concrete Constructed Glass <br /> Newn dk <br /> vd Ta f <br /> SeplicmHOldiux Tank 7� <br /> O <br /> Aaabic',mvlmenl Uvu <br /> ♦O afDe <br /> VII.Responsibility Statement-J,the undersigned,asoma responsibiBly far insolation orlhe POWTS shown on the vBacked plans. <br /> Plumber's Name(Print) Plumber',Signature MP/MPRs Number Business Phone Number <br /> R.c/e H0 h . ,P..G.,aQ ,t/tss / >it— 9L 6— c//J-7 <br /> Plumber's Address(Street,Clry,atom,-p r-m e) <br /> 766 '4,;— 3.f t Jebry�ti [✓Tf-yg9 7 <br /> VII .Cmm /De rl.ent Use 0n1 <br /> Approved ❑Disppmved Sanitary Permit p.ousides GouMwater Dare Issued Issuin [Signature tamps) <br /> Surcharge Fee) y � <br /> ❑Owner <br /> Core Reamnfor Denial V( V /A p<�6(� <br /> Gi <br /> IX.Condition,of Approva..eason,for Disapproval <br /> Am'h somple.phm(ry rN CvunryodY)Iw are rn4m m ppervo(Iuv1Wu,@ i 11 bx8n tn'iu <br /> SBD-6398 (R. 01/03) <br />