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r <br /> Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 I13u rn'G�' <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> iseonsin <br /> Department of Commerce (608)266-3151 8d9 c\ ` <br /> Sanitary Permit Application State Plan I.D.QNumbber x) <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide //V V47V{ O <br /> maybe used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information -s �l .� <br /> Property Owner's Name pD (,O �lJ Parcel# Lot# Block# <br /> !10 ,f_r LO 1" 0h 0J, S - .71 - o37oa <br /> Property Owner's Mailing Address -7 Property Location Q' <br /> /r6 7/ (/✓. Ta 5 r/lWo,`P r <br /> %., V4, Section / 3 <br /> City,State Zip Code Phone Number <br /> Sur r i s r /yet e r 75'- 033 7 (circle ) <br /> II.Type of Building(check all that apply) T 40 N; R_/4 E oeVV <br /> Subdivision Name CSM Number <br /> 1 or 2 Family Dwelling-Number of Bedrooms Kt? CKPinz(`e •L�C'1 G� <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village®Township of SGO 7t�r <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that app 1 <br /> ❑Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil AAt-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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(so System Elevation <br /> 340 . 5— 600 600 9 y. ,;;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 75.6 7.fQ <br /> Aerobic Treatment Unit <br /> Dosing Chamber SOU .S"OQ <br /> VII.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 /> RIc% o /f/'7 S �aSBs"( 7/5= BGG- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> x. 7760 /yw 35` Websf-e,, W_1 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ent Signature(No Stamps) <br /> ❑ <br /> Surcharge Fee) -RL-D' U0 -lq- <br /> Owner Given Reason for Denial J I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> SEP 1 8 <br /> 1 2003 <br /> r�'IRNETT COUNTY _ <br /> -710NINC <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 />