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ON COMPUTER/SCANNED Ex 1011e 'b <br /> I <br /> Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 S.r <br /> consin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 ,I'-Tn?,3A5 <br /> Department of Commerce �'7 / <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide __C' <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information / <br /> L�vc,c� a9 <br /> Property Owner's Name Parcel# Lot# Block# <br /> Jery, Y, et' 011)0 _ <br /> Property Owner's Mailing Address Property Location <br /> 1-71A G k RoP. <br /> City,State Zip Code Phone Number E�= /', Section <br /> W e5 f> e f w-r Sy 5 9_3 ( E ocircle(we) <br /> ICI T � O N; R /6 <br /> }.Type of Building(check all that apply) � <br /> t� 1 or 2 Family Dwelling-Number of Bedrooms S Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> El State Owned-Describe Use ❑City_❑VillageffTownshipof 04-141AH-,t <br /> I11.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. ❑Permit Renewal ❑Permit Revision ElChange of El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner 472216 /Z110101 <br /> 1V.Type 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 ❑ 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(gpdso Dispersal Area Required(sO Dispersal Area Proposed(sf) System Elevation <br /> -7S6 1 . 7 1 /end /080 ?y. o <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 1Goo J/�O / �,��a w <br /> Aerobic Treatment Unit !7 <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,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 /> I?te-AL /2 � a2�s�'S/ 7ir 86 6- S�is7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu' g gent Sign (No Stamps) <br /> Surcharge Fee) p / <br /> ❑Owner Given Reason for Denial an&.0i 4,e pr 430 /U 0 <br /> IX.Conditions of ApprovaMeasons for Disapproval <br /> NO ldf �oRWN47r<D io STD J- <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />