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Suety and Bwldmes Dnision County <br /> 201 W. Washington Avc,P.O Box 7162 QUY Iq e�7� <br /> ��consin Madison. G�1 53707 -716? =tjutNumber Ito be tl rJ in be CoDepartment of Commerce (bns)2bfi 3lsl57 ¢ # /03 x) <br /> Sanitary Permit Application SWtc Plan I D Number <br /> In accord with Comm 93 21,Wis.Adm.Code,personal information you proxide <br /> may be used for secondary purposes Privacy Law,sl i.0.1(1)Int) <br /> Project Address UI Jil ferem than"'ailing uJdress) <br /> 1. :application Information-Please Print All Information <br /> Propcny Owner's Namz <br /> � �oParcel# Lot X Block Y <br /> Property Owner's Marling Address on ress o 0'3 41/08-p3Gdo <br /> / <br /> �g/� w• /u tCf LK Qom(, <br /> Property Location C7 on A�a I `� <br /> City.Slate Zip Code Phone Number " —', Seetion $ I <br /> .6 Wl SY6036 (circle one) <br /> f111.Type of Building(check all that apply) T Oto N, R /7 E or <br /> r(1 or 2 Family Dwelling-Number of Bedrooms 3 Subdrvisiun Name CSM1I Number <br /> ❑Public.Commercial-Describe Use <br /> ❑State Owned-Describe Use []CITY—[] (ITownship of Lim Ory AT, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑ Treatment:HoldingTank Replacement Only ❑ <br /> P y Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit RevisionLtst Previous Pzrmu Nwmber and Date Issued <br /> j11Cha:ng:eof TOEncr <br /> rmit Transfer to NewBefore Expiration <br /> I%'.Tv a of PUTTS System: Check all that a Iv <br /> 1�Non-Pressurized In-Ground ❑ Mound>23 inof suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Linc ❑Other(explain) <br /> ❑Gravel-less Pipe ( p <br /> V.Dis crsal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 4`!ry . 7 6-9`3 G y 8 93. e <br /> %7.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Plastic <br /> Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Scpnc or Holding Tank 14Q /41649 <br /> Aerobic Treatment Unit <br /> Dosing Chamber 4606 �OO <br /> %1I.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP MPRS Numerb <br /> ) p Business Phone Number <br /> � - �15 <br /> Plumber's Address(Street,City,State,Zip Code) lis-6`4 4 . 7 <br /> di760 'c`u'r 3s' we•bS;ile� <br /> VIll.County Ue artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued ISSL':n en Signature (amps) <br /> Surcharge Feel <br /> ❑ 26Owner Given Reason for Denial 0 I�GY <br /> I\.Conditions of.Approval/Reasons for Disapproval <br /> Attach complete plans pa the County only)for the system nn paper not Ices than tlt/2 s I I inches in sit <br /> SBD-6398 (R. 01/03) <br />