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• ()MPI ITERISCANNED _ <br /> Safety and Buildings Division ° Count;/� <br /> ` j 201 W. Washington,Ave.,P.O.Box-' 62 � l3." t?1T' � <br /> �SC����� Madison,WI 53707--7 162 Sanitary Permit Number(to be filled m tDy Co <br /> P (608)266-3 151 i J -7 � j <br /> De artment of Commerce "-]' l <br /> Sanitary Permit Application state Plan I D.Number <br /> In accord with Comm 8321,Wis.Adm,Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(I)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information W <br /> 4 l3? 7767 P--ospeec)`" <br /> Property Owner's Name Parcel# Lot# Block# <br /> i ke- /7a u lSmn ©Ao 9,18,41 01300 <br /> Property Owner's Mailing Address Property Location <br /> • /36,tp <br /> SW %., SW ., Section %49 <br /> City,State Zip Code Phone Number <br /> �q Ftl N Al/!� SSA 7 7�03-4d/—/O// T yd N. R (circle oge) <br /> E or <br /> Il.Type of Building(check all that apply) <br /> LW1 or 2 Family Dwelling-Number of Bedrooms 3 1Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use V I I t5 <br /> ❑State Owned-Describe Use ❑City_ Village gTownship of 04k140 � - <br /> IIl.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. arNew System <br /> y ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System; <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> LLXNon-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 ❑Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> `fS d . S" 1 9( 173.7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank �d OO /oOB _7— .S/C'a Ai <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> V1I.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rle_/c �e�S�s/ 7/s= �66-�i/s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> al 776Q X1 3s <br /> VIII.CountV/De artment Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuin a Si atu o Stamps) <br /> Approved ❑Disapproved Surcharge Fee) //-- g P <br /> ❑Owner Given Reason for Denial $ t� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> KSUISrOYO TO Q SU 1n3FGTRJtT /�►YE 4OChT(aJ &F SSoL A6i;6lWIJ4�1 <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 />