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Safety a::ve., <br /> ings Division County y( <br /> 201 W.WashAve,P.O.Box 7162 Q(J rA/GTf <br /> Visconsin Madiso3707-7162 Sanitary Perrot Number(to be filled in by Co.) <br /> Department of Commerce 3151 53.Z 1777 <br /> State PI Number <br /> Sanitary Permit Application � ur� <br /> In accord with Comm 33.21,Wis.Adm.Code,personal infunmaron you provide <br /> maybe used for secondary purposes Privacy taw,s15.04(Ixm) Project Address(ifdifferent than mailing address) <br /> 1. Application Information—Please Print All Information C) U.�s6.Ba15s,GaK` <br /> Property Owr er's Name / Parcel M GSM I A261at p Block tl <br /> o,6 0 I " a- az_ d123- o don <br /> Property Owner's Mailing Address Property location <br /> 29H 70t'`' l'Jf /V 6w• LoT 2 �r Z <br /> AN)%4 51�%., Section Z/ <br /> City.State {�}�,/ Zip Code Phone Number <br /> 4446m .e4f /r•la' �,� T'Y�N: REco ) <br /> If.Type of Building(check all that apply) <br /> Q0I or 2 Family Dwelling—Number of Bedrooms 2 Subdivision Namee CSM Number <br /> ❑Public/Commercial—Describe Use 4�� —" U1 -2 <br /> C1 State Owned—Describe Use ❑City_❑Viliage'�fownship of v Ao rj <br /> 111.Type of Perunit: (Check only one box on line A. Complete line B if applicable) — _ — — — — — �D <br /> A. El New System rKeplacement System ❑TrestmrnVHolding Tank Replacement Only ❑Othu Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer ro New USE Previous Permit Number and Date Issued <br /> 13efore Expiration Plumber Owner <br /> Or <br /> IyV.Type of POWTS System: Check a6 that apply) <br /> l(r Non—Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable and ❑At-Grade ❑Single Pass Sar!Filter ❑ <br /> ConstructedWetland ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Lcaehmg Chamber ❑Drip fine ❑Gaavel-lessPipe ❑Other(explain) <br /> V.Dis ersal/Treatment Area Inform ttio6: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Ares Required(s0 Dispersal Area Proposed(sD System Elevation <br /> 36 1 . 7 y3z y3Z 94'50 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Editing <br /> Tamkz Tudor <br /> Septic or Holding Tuik <br /> Aerobic Trearmea Unh �C.J <br /> Dosina Chamber <br /> VII.Responsibility Statement- 4 the undersigned,i same responsibility for installation of the POWfS shown on the attached plans <br /> PI 's Name(Print) plum f s Si MP/MPRS Number Business Phone Number <br /> 101 �11� / �✓ gsl°/S 7, 866-8o74O <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z d 3 tar ioe✓ e/ Inl�,(a cr l,✓•: �fg9 <br /> Vlll.Coun /De artment Use Ont <br /> Sanitary Permit Fee(includes Groundwater Dere Issued Issui t Si re(No Stamps) <br /> Approved ❑Disapproved Surcharge Fee) �x ,µ1 <br /> 11 Owner Given Reason for Denial ✓ 4' `"'�, <br /> IX.Conditions of Approval(Ressons for Disapproval <br /> AtWh enmplete slue 06 die Cavy eay)ret tlr sysern r paper nnl less tlw 512 x 11 inehe im slu <br /> SBD-6398 (R.01/03) <br />