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Safetyand Buildings D,visiun i County <br /> ZUI W. Washington Ave., P.O. Box 7152 <br /> Isconts�n Madison, WI 53707-7162 <br /> De artment 0f Commerce 1608)266-3151 Sall 1,11 T11 Permit Number(m be Pilled in by Co) <br /> Sanitary Permit Alicatio `mss <br /> Application n t91 <br /> i Stae I.D..DPlan 1Number ` <br /> I*'accord with Comm 83.21,Wis,Adm.Godo,personal iaforitution you may be used for second p Y ' provide <br /> tuY purposes Privacy Law,s15.04(lkm) Project Address(if differem than mailing address) <br /> I. AppUcatton Information-Plow print All Irdor•matlon <br /> Properly Owner's Na me <br /> parcel P Lot! Block k <br /> s uat. <br /> Popty< Ow/etrP'e Mo ailtg Address <br /> i Cl�{- y � <br /> iJ <br /> Property Location <br /> Lk t COT <br /> �W <br /> 1�1u� 21pC,o/de Phone/Number �j ---- `A'• u•Secdon <br /> W ���� 5`� 9 93 3 7 c( -a.3S / (circle , <br /> II.Type of Building(cheek all that apply) T 3 8 N; R L5LE or V <br /> I or 2 Family DwWljng-Number of Bedrooms <br /> Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use f <br /> Q State Owned-Describe Use <br /> ❑City_QVillage ownship of &6ELla f,- <br /> III.Type al'ru=tl (Check curly one bax on IEue Jill Una B iP applicable) <br /> A. �New System Q Ae <br /> placametu System Q TreatmendHolding Tank Replacement Only I ❑ Other Modification to Existing System <br /> B. Q Permit Renewal Q Permit Revision Q Change of List Previous Permit Number and Date Issued <br /> Before Expiration 6 Q Permit Transfer to Now <br /> Plumber Owner <br /> V. Tyra of POWTS System (Check all that anoly <br /> Non-Pressurized In-Ground �] Mound > 24 in.of s titable soil Mound < 24 in. of suitable soil L At Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Wetland 0 Pressurized In-Ground 0 Holding Tank Q Peat Falter C Aerobic Treatment Unit a <br /> Q Recirculatin S nthadc Media Filter a3 t.eaching Chamber u Drip Line Q Grave;-cess pipe El Other(explain) Recirculating Sand Filter <br /> V.Dig rianreatment Area Information. <br /> Design Flow(gpd) Design 5011 Application RecrKgpdsfl Dispersal Ara Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI. Tank Ialo Capactry in Total Number __� <br /> Galloro Gallons of Units�anufacturu Prefab Site Steel Fiber I Plastic <br /> New Existing , I Concrete Constructed Glass <br /> Tatuta Taus <br /> Septic or Holding Tank + < <br /> DOO l e "_1 <br /> Aerobic Tmataara Unit i <br /> Oaring Chamber <br /> VII.Responsibility Statement- I,the teed ed,aasuute res otssibWt for llation of the POWTS shown an the attached s. <br /> Plumber's Ns me(Print) Plumber's Si <br /> 11 gneture P WKS Number Business Phone Number <br /> 1.Q st 2 S� or e7 7� <br /> Plumber's Arldre u(Street, City,State,Zip Codd) <br /> V , Count /UeG o .rJ l <br /> artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fae(includes Groundwater Date Issued lsaui t S' n <br /> Surcharge Fee; ��O oe' 'A (No Stamps) <br /> ❑ <br /> Owner Given Reason for Denial f r7'� Or( t + <br /> 1X. Condltlotu of Approval/Reasons for Disapproval _ `Y J <br /> 1 <br /> � I <br /> AttatY aeo<Ptate Pbus fro the County oily)Ill the system on lraper not leas tboa st.Z x It incase in sire <br /> SBD-6398 (R. 01/03) <br />