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ON COMPUTER/SCANNED <br /> Safety and Buildings Division County <br /> ® �+ 201 W.Washington Ave.,P.O.Box 7162 U + <br /> I SCO�S`�n Madison,WI 53707—7162 <br /> (608)266-3151 Sa'u�7 Permit Number be filled in by Co.) <br /> Department of Commerce L(r <br /> Sanitary Permit Application stagy Plan I-D.Number <br /> In accord with Comm 8321,Kris.Adm.Code.Personal information you provide 106 ;761 <br /> maybe used for sewodazy Purposes Privacy Law.s15.04(l)(m) Project Address(f different than mailing address) <br /> L Application Information-Please Print All Information !n oZ l a kG�12iU �, rlVJrl <br /> Property Ownees <br /> iNx Parcel# lot# Block# <br /> Property Owner's Ma" <br /> //Address 01 - 672 - �� 4-7U <br /> Property Locatim <br /> city,some Tip Code Phone Number 'b 54 Section ej f <br /> bi,)4sgmy!stSSO <br /> (.. �p (arck <br /> all that <br /> IL Type of Building.(check all apply) T c !! N; R1S2E ort <br /> 1 or 2 Family Dwelling-Number of Bedrooms 7EM Number <br /> PublidComraetcial-Describe Use L/� CT (Into 1 Vln r <br /> State Owned-Describe Use City Village Township of"M✓ 6�C ON <br /> IIL Type of Permit: (Check only One box on line A. Complete line B if applicable) <br /> A. New System <br /> Replacement System TecatmetWHolding Tank Replacement only jOdwr Modification to Existing System <br /> B. Permit Renewal Permit Revision of vious Permit Number and Date Issued <br /> Before Expiration Permit Transfer to New <br /> Plumber Ower <br /> IV.Type of POWTS System: (Check all that apply) <br /> Non-Pressurized in-Ground Mound>24 is of suitable soil Mound<24 in of suitable soil At-Grade <br /> Single Pass Sand Filter <br /> Constructed Wetland Ptessvrized ln-GmuodSynthetic Media Filter Leaching Holding Tank Peat Filter Aerobic Treatment Unit Recirculating Sand Filter <br /> ating ng ChamberRectivA Drip Line Gavel-less Pipe Other(explain) <br /> V.Dispersalfrreatment Area Information: <br /> Design Flow(gpd) =Soilion RaWAIdst) Dispersal Area <br /> Required(st). .Dispersal Area Proposed(st) SystemIIevatim <br /> r - <br /> VL Tank Info <br /> capacity in Total Number Maanfacouer Prefab Site SteelFiber Plastic <br /> Gallons: Gallons of Units concrete Constructed :Glass <br /> New Existing <br /> Tanks Tanks <br /> Septirar Holing Talc � ', ^ _ <br /> Aerobic Twatfflm Umt <br /> Doting Chamber <br /> VII. 'bility Statement-1,the assume responsil tty for' of the POyP1S shown on the attached <br /> PlumtidsName(Few) Plain S <br /> Business Phone Number <br /> pi= rox Z�Z�Z X15-2�Q-3l c} <br /> Ptamrrbets Address(Street City.state,Zip <br /> 2q6 U6SSee <br /> VIII.Co t Use only <br /> Agproved Disapproved �e1 ;Fee(includes Groundar�w Date Issued Sign Stamps) <br /> ✓ S <br /> Owner Given Realm for Denial r <br /> IR.Conditions of Approval/Reasons for Disapproval r/ <br /> OCT 1 s <br /> Attack BURNETT COUAttackl�(lo We('oueiy eolr)for the s7stem oa paper eot less Wan i12 x 11 inches io sin ,r <br />