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--- <br /> j <br /> Aisconsin iat8a in BtWin .Box.0 I W. Washington Ave P U.Box 7162 Madison,WI 53707-7162 Sanitary Permit N mbev(to be tilled in by Co.) <br /> Department of Commerce (608)266-3 15 1 S <br /> Sanitary Permit Application <br /> Susan Plan M.-NI <br /> er <br /> In accord with comm 93.21,Win.Adm.Code,penwel information you provide <br /> maybe used for xcoadafY Purposta Privacy Law,s15.04(l)(m) <br /> Project Addrcas(if diffaeatthan mailitg addteas) V i <br /> 1. Application Information-Please Print AB Infortoack, <br /> Property owner's Nation <br /> Parcel# Lot# Block# <br /> �frL•J SFcI l �Cc.(1+ 001 - 2116 01 o <br /> Property owner's Mailing Address <br /> Property Incation <br /> z y O S_0 ( ). SY-C I I r"(t 4,V, .Sr t l Y.5e section <br /> City,State Zip Code Phone Number <br /> s( e i 1 L4� w i SSI $ 7r s Y 6 8 2 > (circle coal <br /> eIL Type of Building check an that apply) I T 3�N; R <br /> 0 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name CSM Number <br /> ❑Public/Cotnmercial-Describe Use <br /> ❑State owned-Desmbe Use y�ity_❑Village&owuship of <br /> III.Type of Permit: (Check only one box on Hue A. Complete Ilne B if applicable) <br /> ❑New S <br /> yntem eplacerrteat System ❑TreamtenNHolding Tank Replacement only Q other Modification to Existing System <br /> B. <br /> 13 Permit Renewal 13 Permit Revision ❑Change of 1]Permit Transfer m New Lis[Pmvious Pemti[Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that ti1 <br /> [Jon-Ptessuriad lad oAteid ❑Mound>24 in.of suitable soil 13 Mound c 24 in.of suitable soil ❑At-Grade O Single Paes Sand Filter 13 <br /> Constructed wetland ❑Pressmved Inlhwmd 0 Hokling Tauk 0 peat Filter ❑Aerobic Tmonmt Uoit ❑Recirculating sad Fiber ❑ <br /> Recirculating Synthetic Media Fiber ❑L.eaching Chamber 3 Drip Line 13oravemesa Pipe ❑Other(explain) <br /> V.Die rsaVri eatlnent Area Information: <br /> Deai®a Flow(gpd) Design Soil Application Rate(gpdsf) Disposal Area Required(at) special Area <br /> � Proposed(still System Elevation <br /> 300 4-) 9V)`1- 93 - 97 <br /> VI.Tank Info Capacity in Total Number Mmufacnuer Prefab Site Steel Fiber Plastic <br /> Galloon Gallons of Units Concrte Constructed Glass <br /> Ncv Existing <br /> Tanks Tank <br /> Septic or Holding Tack <br /> Aerobic Tresmeo Drat <br /> Dosing Chamber <br /> VII.Responsibility State ment-I,the wade teepee ty r iosbBatlon of the POWTS shown on the attached p6ee. <br /> P bar's Name(Print) Phtm 's S' �w:' MPIMPRS Number Bueiteas Phone Number <br /> -� w as - a_. <br /> amber's Addtees(S City,State,Zip Code` <br /> 0-; 4:l9(-Vk-- 6 ho'* <br /> VIU.ComiltvADentartmeart Ilm <br /> 19 Approved ❑Disapproved Suburry a to Fee(includes Groundwater Daft Island Instant ignat[ue mmpe) <br /> ❑owner Given Reason for Denial Surcharge Fea) if 12,56 10 /6 44 r f <br /> DL Conditions of Approval/Redu ms for Disapproval <br /> Attach compkft ylam Ito the Cosaty oely)for the system oe paper neaase than s V2 x 11 lnchn im see <br /> SBD-6398 (R. 01/03) <br />