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Safety and Buildings Division County <br /> � 201 W.Washington Ave.,P.O.Box 7162 EtpVM-e�- <br /> s�n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Vviscon <br /> (608)266-3151 <br /> Department of Commerce <br /> Sanitary Permit Application State Plan I D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> maybe used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. ApplicationInformation—Please Print Alllnformation oa O <br /> Property Owner's Name Parcel# Lot# ' Block# <br /> /Oc.. & /ltGci Ofd( d41-04 O&Als <br /> Property Owner's Mailing Address Property Location &V,-6, <br /> TgBO W04YN P✓ GK IC7�. <br /> r <br /> �W %., Sw '/q Section <br /> City,Stale Zip Code Phone Number <br /> web S�iB%3 G7/b (circle one) <br /> II.Type of Building(check all that apply) T 3 N; R /S E o® <br /> ®I or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use l-� t <br /> ❑State Owned—Describe Use ❑City_❑Village IDt ownship of Ls Fe <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. .�New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. El Permit Renewal El Permit Revision ❑Change of El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> F Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> ,VNon—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 ❑Gravei-less Pipe ❑Other(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(at) System Elevation <br /> 9.S . 7 1 4043 9.x. 0 <br /> VI.Tank Info Capacity in Total Number Manufacturer PrefabNComtmcted <br /> Fiber Plastic <br /> Gallons Gallons of Units Concrete Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Talc /d00 )� <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,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 /> Rfck ya ln.,J /? a.qj otJ S8S/ 7cS=X66—y/5 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a1 X760 i/... . .sem 2r9:? <br /> VIII County/Department Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issum ge ignatu tamps) <br /> Surcharge Fee) .ry '.12 „/ <br /> ❑Owner Given Reason for Denial U/ e�( <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not legs ch..812 s 11 inches in sin <br /> SBD-6398 (R. 01/03) <br />