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Safety and Buildings Division County <br /> 0 201 W.Washington Ave.,P.O.Box 7162 Z C4 tn/U <br /> ` isconsin Madison,WI 53707-7162 Sanitary Permit NSlmber(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 �P/ u1500 <br /> Sanitary Permit Application State Plan I.D Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide r0 <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) V v <br /> I. Application Information—Please Print All Information <br /> /fid <br /> Property Owner's Name 6 V o O aParcel# Lot# Block# <br /> Prop ity Owner's Mailing Address dd Property Location <br /> C/ /T �,, y. Section 2 Ci <br /> Ci ,State Zip Code Phone Number [/ / <br /> /�-�6�1� G'i s � ��30 �(v 6 �7� � T_L_N; R/ circle <br /> II.Type of Build ng(check all that apply) <br /> Eo <br /> r 2 Family Dwelling-Number of Bedrooms Subdivision Name @9M-finmber <br /> ❑Public/Commercial-Describe Use , .z (2/ o c,} L e c� as(�S / <br /> ❑State Owned-Describe Use ❑ _CityVillage VMwnship of 6h /1 /�t <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/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. 11 Permit Renewal ❑ Permit Revision ❑Change ofJOC:mit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber r <br /> IV.Type of POWTS System: Check all that apply) <br /> ^On-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(st) Dispersal Area Proposed(st) System Elevation <br /> 3 0 �' / 7 .2 '7 �i's�o f S; <br />