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Safety and Buildings Division Coun <br /> ` <br /> 201 W.Washington Ave., P.O. Box 7162 <br /> iseonsin Madison,WI 53707-7162 Sanitary Permit Number(m be filled in by Co.) <br /> Depart of Commerce (608)266-3151 �A5 <br /> Sanitary Permit Application gmte Plan I.D. Isturdwr <br /> In accord with Comm 83.21,Wu.Adm.Cnde,personal information You provide UQ <br /> may be ural for secondary pur,som Privacy Law,s15.04(1)(m) Project Address(if diffuna Wan nailing addres) <br /> 1. Application Information-Please Print AB Information �73 LL-O>7 1 `, n '. <br /> Property Owner's Name Parcel N U,# ' Block N <br /> goes. C ,44.5e, J (!3/oz %zq oz 600 <br /> Property Owns'.Ma ilir,Address P"isn"y do 6,e— <br /> ",id l G k M, 4.Seetkm <br /> City,Sure Zip Code Ph..Number <br /> -S� e nj, 5-5--s 7S) �-(eircle o ) <br /> T N; Rl Eo N <br /> IL Type of Building(check all that apply) <br /> X,or 2 Family Dwelling-Number of Belrooms Sabdvraw, iwde CSM Number <br /> ❑Public/Cnmmendal-@scribe Use <br /> U Stare OWnal-Describe Use (]City �V01a a$1'owmrytp of <br /> e ar✓ <br /> III.Type of Permit: (Check only one box on line A. Complete line B it applicable) <br /> A' ❑ New System %Replacers m System ❑ Tretmnm/Holding Taa Replacement Only ❑ Other Modification in Exuling System <br /> B. ❑ Permit Renswd IJ Permit Revision ❑ flange of ❑Permit 1 mifies m New Lut Previous Permit Number and Date Ixrued <br /> Before Expunion Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> xNon-Pressuriutl In-Ground ❑ Mnund > 24 in.of soluble sod ❑ Mound < 24 in.of suitable not ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Cowm ieatl Wetland ❑ Presurir In-Ground ❑ Holding Tank ❑Peat FdwI ❑ Aerobic Trennent Unit ❑Roeimulat ng Sand Filter <br /> ❑ Recirculating Syntenic Media Filter ❑Leacteng Chamber ❑Drip Lim ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dns go I remmen[Aree Information: <br /> Deign Flow(gpd) Deign Soll Application Raw( off Dispersal Arm Required(a) Dispersal Area Proposal(ser Sy...Elevation <br /> Zoo a 7 8 00 6 <br /> VI.Tank Info Capacity in Total Number Mamnfxmrn Prefab Sire Steel Fiber Plastic <br /> Gallons Gallons of Units Cmocree, Constructed Glus <br /> New laming <br /> Ta T <br /> :j <br /> Seplir in BeMmgira <br /> Aerobic Treaurcm17 Unit <br /> Dosing Clamber SD 73O /T <br /> VII,Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached Plans. <br /> Plumber's Name(Prin 1) Plumber's Signs m MP/MPRS Neither Bnsitaea Phnrc Number <br /> 6) <br /> e 1�M Gr/ �---7� q � 7�P <br /> Plumber'.Address(Street[,City,State,Zip(ode) <br /> e7— <br /> VIU.Cowtv/Dereartment Use Only <br /> Approval ❑ Disapproved SWury Permit Fee(Melotia Groundwater Date Issues] lou' or Si o Sump.) <br /> Surcharge Fee) <br /> ❑ Owner Given Recon for Denial <br /> IX.Conditions of Approval/Reasmm for Disapproval <br /> AmW mmpbm Islam(m 0e County mlY)gar rhe poem m paper an was Wan In x 11 buten m she <br /> SBD-6398 (R. 01/03) <br />