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Safety and Buildings Division County <br /> Nvisconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 U14.14 nf Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 at,f 29 35Z <br /> Sanitary Permit Application Ste 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,s 15.04(1)(m) Project Address(if different than mailing address) (� <br /> I. Application Information-Please Print All Information 4 I� J � /_ i) /l. -�1 <br /> IProperty Owner's Name I Parcel# (Lot# r/Il L�IY. Block# <br /> 03a-91yo-ol- <br /> wre f/e( soul is <br /> Property Owner's Mailing Address <br /> 3 o68Property Location <br /> 0464lava(lmark (� � 3� <br /> City,State �r Zip Code Phone Number —�°� . '�°, Section <br /> Gh cSa a- (� 5���� �p✓tel s+)J� 7-<{�l f' _(circle <br /> Il.Type o Building(check all that apply) 7 T y� N; R l�E ol� <br /> PP Y) ..Q <br /> K1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use 4Os'r Ac-f4�S <br /> ❑State Owned-Describe Use ❑City_❑Village Township of S W td i E <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. . stem NewS <br /> System El Replacement System ❑ Treatment/Holding Tank Replacement Only L1 Other Modification to Existing System <br /> B. LJ Permit Renewal El 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 apply) <br /> •L 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 7 6 5(3 E qS 17,111. 6 <br /> VI.Tank Info Capacityin Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> SeTanks Tanks <br /> ptic or Holding Tank S/ei� <br /> Aerobic Treatment Unit a �'W <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) her'`Sign` MP/MPRS/Number Business Phone Number <br /> �10dri G�C �>�0 S � 7/5=r6�v- 91S�� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee includes Groundwater Date Issued Issuin ge Signatur Stamps) <br /> Surcharge Fee) I ^�,1 03 <br /> ❑Owner Given Reason for Denial /1l✓L/!71 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> r " r V <br /> I <br /> U <br /> AUG 2 2 2003 <br /> Attach complete plans(to the County only)for the system on paper not less then g1/ x Il inches <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />