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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 0(`Na.J <br /> l���O��I� Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-315122 jr 9 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name I Parcel# Lot# Block# <br /> kevc),J 400-At3 2©l-IlD <br /> Property Owner's Mailing Address Property Location <br /> Zf75- w AIL <br /> 132- <br /> City,Stattne// Zip/Code Phone Number ey / �� V., '/., Section <br /> WCJF�IJ�� �G ?Bg M- 7756 /UJ (dEo ) <br /> 11.Type of Building(check all that apply) <br /> VI or 2 Family Dwelling—Number of Bedrooms Z. Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> ❑State Owned—Describe Use ❑City_❑Villageownship of ®R / <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement System ❑ Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System <br /> BList Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑ Permit Revision IJ Change of El Permit Transfer to New <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> C Non—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 ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <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 <br /> Septic or Holding Tank Dv <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI er's Name fPrmt Plu is Signator MP/MPRS Number Business Phone Number <br /> t'C�wr4 ,�r�'S ZZ5 / e966-�a'/S <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27p 0 lbw w P,�vs � Lye' 2 <br /> VIII.Court /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui it Signa o Stamps) <br /> Surcharge Fee) <br /> El Given Reason for Denial � �(O A bsi L-21 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plum(to the County only)for the system on paper not less than 8112 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />