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Safety and Buildings Division County <br /> 201 NW.Washington Ave.,P.O.Box 7162 1-3u/'N e741 <br /> iseonsin Madison,Wl 53707—7162 Sanitary P rmit Number(to be filled in by Co) <br /> De artment of Commerce (608)266.3151 6 3 <br /> Sanitary Permit Application State Plan I.D.Number C1J <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide oZ)a C7 0 <br /> may be used for secondary purposes Privacy Law,s15.04(I)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information n d <br /> S•(A71 ��ld1Yl5 �- <br /> Pro pe Owner's Name Parcel# Lot# Block# <br /> >�O . ) <br /> Property Owner's Mailing Address Property Location PG <br /> Section <br /> City,State / Zip Code ,/ PhoneNumberone <br /> G <br /> U-/'f}N 64!` w sy�70 6 —5762 T �4 N: R�Eo(�' ) <br /> ll.Type of Building check all that apply) <br /> V(A ort Family Dwelling-Numberof Bedrooms �- Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑village ship of <br /> rJ <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permi:PR,enewal ❑ Permit Revision ❑Change of ❑Permi['fransCer to NewList Previous Permit Number and Dale Issued <br /> Before Eration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil 'Ja-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.Disfacirsall7reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(sf) System Elevation <br /> Sao 1 :5— Soo 99 y-- <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 <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(Pr pt) Plumber's Signature MP/MFRS Number Business Phone Number <br /> evwlle x0oll" r Gr/ -L- <br /> Plumber's Address(Street,City,State,Zip Code <br /> V I.Count /De artment Use Only <br /> Sanitary Permit Pee includes Groundwater Date Issued issumllipigent Signature(No Stamps) <br /> Approved El Disapproved Surcharge Fee) 7 • � /I-of-psm/i, .� <br /> El Owner Given Reason for Denial c-u�/ l <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on palmy not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />