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ON COMPUTER/SCANNED <br /> ` Salcty and Buildings Dictsion County 301 W. «'ashington Ace., P.O. Box 716_2 6'vrNeT <br /> iseonsin Madison, kk 1 53707 -7 162 Sannary Pe nit Numher to be filled in by(_o) <br /> Department Of Commerce (608)266-3151 ���z <br /> Sanitary, Permit Application stale Plan I D Number <br /> In accord with Comm 33_'1.%k is.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15 OJt I)(m) Project Address(ifdifferem than niaihng address) <br /> I. Application Information-Please Print All Information -7 <br /> ( w m <br /> Properly Owner's Name E&Parcel a Lot <br /> �• —Block 4 <br /> 5 od <br /> Propenv Owncr's Ntailmg Address Property Location <br /> 7#City,State Zip Code Phone Number ML Section z, <br /> 7e b LL ��//V �l0 7T —ti2$1 T #0 � � <br /> �11.1.Type of Building(check all that apply) N: R Eo <br /> 1r I or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name CSM Number <br /> ❑ Public Commercial-Describe Use hiI I esm 1, g /� <br /> ❑State Owned-Describe Use ❑City_❑Village,NTownship of JaG N <br /> 111.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:1o:Existing System <br /> R. ❑ Permit Renewal ❑ Permit Rev ision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of PONTS 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 U <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/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(sf) System Elevation <br /> 3so . 7 yz I yTz 19y0 <br /> l7.Tank Info Capacity in Total Number Ntanufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank — goo <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> %If. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the PO%kTS shown on the attached plans. <br /> Pl��nber's Name(Pant) Plumber's Signature MP N1PRS Number Business Phone Number <br /> K;c�i �l`r z2u l9sl 7 <br /> Plumber's Address(Street,City,State,Zip Code) -`/5 <br /> VIII.County[Department Use Only <br /> Approv7dE] Disapproved Sanitary Permit Fee(includes Groundwater Date -sued Issu.n . gem Sign o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial <br /> 1\.Conditions of Approval/Reasons for Disapproval <br /> Attach complete,plans(to the County only)for the system on paper not less than 8tr2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />