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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 71ti2 84ArA�e77— <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> IVAIsconsin <br /> (608)266-3151 4 72 Z G 7 <br /> Department of Commerce / <br /> • <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> d905$ Gonq Lk IF,4• UJ <br /> Property Owner's Name Parcel# Lot# Block# <br /> 1oHI krn sbur ��g— q/OQ— Doff—£5'C3O <br /> Property Owner's Mailing Address Property Location 60V,L. <br /> `705g Z,121 G.le e Rot. W <br /> City,State Zip Code Phone Number Y4, ��'. Section S <br /> 0an6rtiry trJr stiese 7/-< 77 00113 (circle one) <br /> T 40 N; R /w E or'(V <br /> II.Type of Building(check all that apply) <br /> I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use CSty\ `\/, v e I-79 <br /> ❑State Owned-Describe Use ❑City_❑Village Township of SeoYr" <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System PrReplaceinenL System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B <br /> ❑Permit Renewal ❑ Permit Revision El 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 apply) <br /> §ZNon-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.Dis ersal Treatmeut Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(si) System Elevation <br /> 19 1 . 7 64g 9�,t,r <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 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <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 /> IRIGIL /`7/O �� I�.- u� -gS/ 7/S"- S'66- X9/,$`7 <br /> Plumber's Address Street,City,State,Zip Code) <br /> 7 7&1 /,�w 3s w 9'?3 <br /> ifCoun /De artme it Use Only <br /> II Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater I Date Issued Issuing t Signa Stamps) , <br /> Surcharge Fee) ` ,,n <br /> ❑Owner Given Reason for Denialtd�s <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/3 x 11 inches in sin <br /> SBD-6398 (R. 01/03) <br />