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Safety and Buildings Division County L� <br /> 201 W. Washington Ave.,P.O. Box 7162 rme <br /> Visconsin Madam wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 \55 1 Z O <br /> Sanitary Permit Application State <br /> Plan <br /> LI.D.Number <br /> In accord with Comm 83.21.Wis.Adm.Code.Personal information You provide (/t7t^+c ul CbJ <br /> may be used for secondary purposes Privacy Law,sl5.04(lXm) Project Address(if different than mailing address) <br /> 14QQ*4 A* <br /> 1. Application Information-Please Print All Information /� � _ A <br /> Property Ow is Name L Parcel# Lot# Block# <br /> 1/4 /Jv��cc 018 3>IAI0160 <br /> Property Owner's Ma iling Address Property Location <br /> ZZ' 6 A ,u fh N4 uN WA <br /> , .Smuon Py <br /> City,State Zip Code Phone Number <br /> V le 4- ln�a- `i y�89 75-7 • 003 7 / ircle oce) <br /> II.Type of Building(check all that apply) T N; RcE or W <br /> 1 or 2 Family Dwelling-Number of Bedrooms d -gyp 'j Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village wownsbip of� <br /> III.Type of Permit: (Check only one box on line A. Complete lice B if applicable) 09-0/ 'z'j9�/a'�1{•$ 1•�A7-OIlODO <br /> A" ff New System ❑ Replacement System ❑Treararra/fiMdirg Tank Repfuenamt Only ❑ 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 System: (Check all that ) <br /> ❑ Non-Pressurimd In-Ground ❑ Monad > 24 in. of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Wedand ❑ Pressurized in-Ground "Bolding Tank ❑Peat Furter ❑ Acrobw Treatment Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Linc ❑Gmvd-fess Pipe ❑Other(explain) <br /> V. DispersaVrreaftnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsI) I Dispersal Ates Rap ted(:t) I Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Gpachty in Total Number Mamtacnoer Prefab Sire Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tads <br /> Septic or Bolding TankZore.t mJ f <br /> Aerobic Treatment Unit 1tiV/ K <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,aswome reWonmb ty for mslaBatian of the POWTS shown on the attached plans. <br /> Plum 's Name t) Sigru` t rek MP/MM Number Business Phone Number <br /> 0 `�,tdf/ Pk'Xf'.�l/� <br /> Plumber's Address(Street ,City,State,Zip pt ) <br /> Z72 o Jq•N7r� 6f (/JeZ* - GJ,-e0tf <br /> VIII.Cotmt /De entUse Only <br /> 5rApproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui ent Signa o Stamps) <br /> ❑ Owner Given Reason for Denial <br /> Stere Fee) 3 7.5� x 4z <br /> ylA <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach rn pkle pians(10 the County only)for the rystem w papa ere fns than alt x 11 hides in sine <br /> SBD-6398 (R. 01103) <br />