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Safety and Buildings Division County �y �, <br /> 201 W.Washington Ave.,P.O.Box 7162 �I�I)k f J E1 T <br /> ` /�®1!c//'� Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 7T15 78 1 <br /> Sanitary Permit Application State Plan I.D.Number M <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15 04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# Lot# Block# <br /> CfMI—c s a MAZN/ MM FRES+I 1)4,-41107-v 2)DZ <br /> Property Owrier's Mailing Address Property Location <br /> /L4 1] VULc1e.AQ Ur SP Y, NJ W%, <br /> %, Section C) <br /> City, <br /> ``State <br /> Zip Code }� Phone Number <br /> 1 'i oQ�ne) <br /> T 40 N; R ��E ortL>A <br /> X11..Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> 1or2Family Dwelling—Number ofBedrooms <br /> ❑Public/Commercial—DescribeUse WNW <br /> ❑State Owned—DescribeUse - ❑City_❑Village%Township of UNIV <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System %Replacement Systemg Tank Replacement Only <br /> ❑Treatment/Holdin ❑ 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 Svstem: Check all that ap I <br /> XNon—Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 inof 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 ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) //Dispersaa�,Area Proo2p,oseyd�,(sf) SSystt7emQElevationp� <br /> �n 6� 4ty) [o2Z l�d 11'66 Dr / 7i z9 -4- t /,!� <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 �,rpry <br /> Septic or Holding Tank boo AOL) YVtt-'�S _V <br /> Aerobic Treatment Unit VV <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigne ssume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) um e s S' azure MP RS mix Business Phone Number <br /> AFF ro- X 64ZZ232 SIS-291-3/91 <br /> Plumber's Address(Street,City,State,Zip Code) JY <br /> P©. 295 hRlsSSE2 WI 541YR <br /> VIII.Coun /De artment Use Only <br /> M Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui n<Signature tamps) <br /> Surcharge Fee) O JONAV,�'/ <br /> ❑Owner Given Reason for Denial JONAV <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> � ac4l� V � 1 <br /> !� 1Ngy _ i <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x Il inches r e- V uA t <br /> 4`(JNING t N <br /> SBD-6398 (R. 01/03) <br />