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Safety and Buildings Division Count /' <br /> ` 201 W.Washington Ave.,P.O.Box 7162 <br /> pisconsin Madison, ) 6-315-7162 FS=fary permit%tuber(to be fille(608)266-3151 -tJf7 <br /> ent of CommerceSanitary Permit Application e Plaan I Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 2� 01 q I <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) PTOjectAddress Efdifferent than mailing address)) <br /> I ;L �7 (�stlsw, { ,t�[�ps <br /> I. Application lnformation-Please Print All Informal iQl <br /> i <br /> P r y Owner's Name O Parcel k Lo Block k <br /> t s It goo <br /> Property Owner's Mailing Address Property Location�. /..♦. <br /> v <br /> 5Dq 114e4 o6,!s V� f 33 <br /> City,State Zip Code Phon<Number G �A• Section <br /> red <br /> Ign N; ■ & ol� V/J <br /> 11.Type of Building(check all that apply) <br /> I 012 Family Dwelling-Number of Bedrooms SubdivisionNme CSM Number <br /> L:Public/Commercial-Describe Use a�( <br /> .�� State Owned-Describe Use ❑City_❑Village yaTownship o <br /> 111.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A, ew System y ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modi[cation to Existing System <br /> BList Previous Permit Number and Date Issued <br /> ❑ Penni[Renewal ❑ Permit Revision L3 Change of ❑Permit Transfer to New. <br /> Before Expiration Plumber Owner <br /> IV.Tv e of POWTS System: Check all that apply) <br /> ❑ 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 Writhing Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Ritix irculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Floow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(SO Dispersal Area Proposed(at) System Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic _ <br /> Gallons Gallons of Units Concrete Co strutted Glass <br /> Ncw Existing <br /> Tarks Tanks <br /> �Sepuco olding Te <br /> I ^J Vc I tee <br /> Aerobic Treatment Unit <br /> Dosmg Chamber <br /> VII.Responsibility Statement- 1,the unilersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plp�qcr' Name(P nl Plu ber's Signature MP/MPRS Number usiness Phone Number <br /> lve ofr 2i r7 d'�6 <br /> Plumber's Address(Street,City,State,ZIP C e),7 e 14,S7 f / - <br /> co <br /> Vill.CountyfDe artment Use Only <br /> Approved ❑ Disapproved Sanitary Penn it Fee(includes Groundwater Date Issued Issuing It ignature tamps) <br /> Surcharge Fee) <br /> ❑ 3aP <br /> I Owner Given Reason for Denial � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> I <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in lu <br /> SBD-6398 (R. 01/03) <br />