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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O. Boz 7162 we* <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department Df Commerce (608)266-3151 -5 S <br /> Sanitary Permit Application State Plan I.D. Number <br /> In accord with Comm 83.21,Wis.Adm.Code,persomt information you provide wu/—/ <br /> may be used for secondary purposes Privacy Law,s15.84(Ixm) Project Address(if different than mailing address) <br /> 1. Application Information-Phase Print All Information C Z Lo <br /> Prope Owner's Name —J Parcel/ �39-/4-2F/a3'Ap0'grBl�M <br /> /V TRUST FfFdRACAS PP 366L IR.v Zov� <br /> PropertyOwner's Ma iling AddolsProperty Location 1b/ to <br /> Of6 6 W-A, <br /> C1 (r(7 <br /> C1 State Zip Code PhoneNumber <br /> • "/Z� ` Z (circle <br /> II.Type of Building(check all that apply) T�N: R�E or ' <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name CSM Number <br /> ❑PublidCommemial-Describe Use <br /> ❑State Owned-Describe Use ❑City_11Vdlage40Township ofAejW v/ <br /> 111. Type of Permit: (Check only one box on line A. Complete line B if apptinbk) <br /> A. ❑ New System VReplaceareM System ❑ Trmmxva/FMWing Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Chmge of ❑Permit Trnnfei 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 /> 9Non-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 ❑Mat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filter ❑teaching Chamber ❑chip Lire ❑Gravd-less Pipe ❑Other(explain) <br /> V.Dis rsal(Treatment Area Information: <br /> Design Flow(gpd) Design Soil A kation Race(gpdaf) Dispersal Area Required(s0 Di Area Pro <br /> 3� �Pl �Zf 4� posed(st) System 7 Elevation <br /> VI.Tank Info CapacityinTotal Number Marmfscoucr Prefab Site 6/ Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 7 Ito <br /> 17 A <br /> Aerobic Treaurent ✓`� <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume respmv'bBky far imlaltatiou of the POIM shown on the attached plans. <br /> PI is Nmne Prin t 'a Si r MP/MPRS Number Business Phone Number <br /> �.�Od' <br /> Plumber's Address(Street ,City,State, Cade) <br /> OM!7o Tqmr�56n3 r LJ; y�y <br /> VIII. ounty/pTartment Use Only <br /> Approved ❑ DisapprovedSanitary �it Fee(includes tGroundwater Date Issued Issuin ge ignam o SSurcharge tamps) <br /> ❑ Owner Given Reason for Denial ��"+u' . '2U/ ` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> AUG 1'9:2011 <br /> Attach comptele plans(to the Comfy only)for the syN®ere pepv not less ihm 8112 x 11 inclan is CO(JNTY <br /> SBD-6398 (R. 01/03) ZONING <br />