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Safety and Buildings Division fanitaryPemit <br /> ` m 201 W.Washington Ave.,P.O.Box 7162 <br /> Iseonsin Madison,WI 53707-7162 mber(to be filled in by Co.)De artment of Commerce (608)266-3161 z 3D <br /> Sanitary Permit Application mberIn accord with Comm 83.21,Wis.Adm.Code,personal information you providez9 w <br /> may be used for secondary purposes Privacy Law,s15.1M(1)(m) Project Address(if different than mailing address) <br /> I. Application Informstion-Please Print All Information <br /> 3 a GVAVQsIfq /?cQ• <br /> Property Owner's Name Parcel# Lot# Block# <br /> (�et L_,w OJ�D- 4"1, 01 6010 <br /> Property <br /> 7Owner's Mailing Address Property Location <br /> GJ oX SPI/ <br /> City Slate Zip Code Phone Number ��� _kel., Section 3 Ei <br /> GvaN,'s6u. WZ S4P'ID 71-4- 63- 3,190 (circle) <br /> 11.Type of Building(check all that apply) T el& N; R /6 E o <br /> I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSMNumber <br /> ❑Public/Commercial-Describe Use - <br /> ❑State Owned-Describe Use ❑City_❑Village Orownship of OAklwwaf <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. X New System Y ❑ Replacement SystemJE] ment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑PermitRenewal ❑Permit Revisionge of ❑Permit Transfer to NewList Previous Permit Numberand Date Issued <br /> Before Expiration Owner <br /> IV.T of POWTS S stem: Check all that a 1 <br /> ❑ Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil Z Mound<24 in.of suitable will ❑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. Dig ersal Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(so System Elevation <br /> 4iro . 9 yso soy 97x3 <br /> VL 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 <br /> /960 /OBD <br /> Aerobic Treatment Unit <br /> Dosing chamber 66e XA4 <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 <br /> Business Phone Number <br /> /[/Gk ye �inJ S"9S/ In <br /> /S7 <br /> Plumber's Address(Street,City,Slate,Zip Code) <br /> X760 h'w 3Sf.(/Gdsf�i Gf/S Sy 893 <br /> VII Conn /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Gr03( 7nd�ter !7 <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Asach complete plum(to the County only)for the system om................ <br /> aper oot las than 812 s 11 inches im siu <br /> SBD-6398 (R. 01/03) <br />