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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,Wt 5370.7—7162 Sanitary Permit Number(to be filled in by Co.) <br /> isconsin 459054 <br /> - <br /> Sanitary <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide luN5 3 <br /> may be used for secondary purposes Privacy Law,sl5.04(I)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information <br /> I <br /> Proen Owner's Name Parcel 4 Lot is Block# <br /> u v vt-e f-+ rc f Cd —c' el`f 700 <br /> Prop�gy�Owner's Mailing Address Property Location,' <br /> ` l� 'h �_ <br /> , T/., Section <br /> City,State Zip'Co/de Phone Number/ <br /> 7/- C6 _2W 2Q- cle J <br /> T ��f�N; R or� <br /> IL Type of Building(check a that apply) <br /> ❑ Na <br /> 1 or 2 FamilyDwellingNumber of Bedrooms Subdivision <br /> ❑ Public/Commercial-Describe Use CS •�/m/e CSM Number <br /> V, (a <br /> State Owned -Describe Use ❑City_❑Village XTowriship of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I(New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Perini[Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Tyke of POWTS System: (Check all that apply) _ <br /> 1 Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑' <br /> Constructed Wetland ❑ Pressurized In-Ground R Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter Q Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V. Dispersal/Treatment Area Information: <br /> I Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> V'l.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber 1 Plastic I <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks _ <br /> Septic o Holding <br /> Aerobic Treatment Unit <br /> r Dusmg Chamber <br /> I <br /> V11.Responsibility Statement- I,the u dersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) mber's Signa re MPIMPRS Number Business Phone Number <br /> P <br /> PSS el ,� 1,1� 17/S- gt-6 s6cr <br /> Plumber's Address(Street,City,State,Zip Code) <br /> _7 ?IFS c� �, FJ JI) W • �_Y sr-`7 s <br /> VIII.Counry/De artment Use Onl <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issui nt Signal e o Stamps) <br /> Approved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Reason for Denial �t <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> i <br /> I <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br /> M <br />