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Safety and Buildings Division County !' /1 <br /> 201 W.Washington Ave.,P.O.Box 7162 N L�+P (-�' <br /> ` Madison,WI 53707-7162 San ita omit Number(to be filled in by Co.) <br /> iscons (608)266-3151 <br /> t8 <br /> Department Of Commerce State Plan I.D.Number �f <br /> Sanitary Permit Application IJ J <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> Project Address(if different than mailing address) <br /> may be used for secondary purposes Privacy Law,s15.040)(m) <br /> 1. Application Information-Please Print All Information <br /> q sd /fes II Rd <br /> I'�` Block o <br /> Property Owner's Name ' Parcel it Lot% <br /> ` F y � Property Location 6Q yr /-pT <br /> 1 <br /> Property Owner's Mailing Address �/ a /� <br /> / 13t O S Q 1'C[i �y/ Y t `--�= G —'/,, - _ ./., Section <br /> C in,State Zip Cood'ee l Phone Number �yrrc <br /> �^ Y R'S' coeo <br /> 11.Type of Building(check all that apply) Subdivision Name CSM Number <br /> 1 or 2 Familv Dwelling-Number of Bedrooms <br /> ❑ Public%Commercial-Describe Use <br /> []city llagc Township of SV_4 <br /> -�State Owned -Describe Use <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ANew System D Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> te Issued <br /> B. Permit Renewal ❑ Permit Revision D Change at ❑Permit Transfer to New <br /> 'I List Previous Permit Number and Dai <br /> Before Expiration Plumber Owner <br /> I�V._Tvpe of POWTS System: (Check all that apply) _. — �- <br /> ❑ Pass Sand Filter <br /> Single " <br /> Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil Ll Mound<24 in.of suitable soil [IAt-Grade g ❑ <br /> Constructed Wetland [I Pressurized In-Ground ❑ Holding Tank ❑Peat Filter <br /> ❑ Aerobic Treatment Unit D Recirculating Sand Filter <br /> ❑Leaching D Drip Line D Gravel-less Pipe D Other(explain) <br /> Recirculating Synthetic Media Filter g Chamber <br /> V.Di ersalfTreatment Area Information: Dispersal Area Proposed(so System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(sD P ��.� <br /> oo , 7 q1? C/5 8t <br /> -- - <br /> Prefab Site Steel Piber Plastic ' <br /> VI.Tank Info Capacuy in Total Number Manufacturer Concrete Constructed Class <br /> IIIGallons Gallons of Units <br /> Ncw Existing -� <br /> Tanks Talcs _ <br /> cptic Holding Talc Ul/e,5f r <br /> Ir �roblc Treatment Unit - ---1 <br /> Dosing Chamlur <br /> VIL Responsibility Statement- 1,the u erslgned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI ber's Signorina MP/MPRS Number Business Phone Numberr-�/ <br /> Plumber's Name(Pti ) LZ's� -7/ (�5 <br /> U 'C J <br /> P umber's Address(Street,City, ate,Zip Code) <br /> �{S Ce (?J (y i > <br /> VTII.CounrvfDe artment T" <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing t Signatu o Stamps) <br /> Approved D DisapprovedSurcharge Fee) <br /> ❑ Owner Given Reason for Denial <br /> II�onditions of Approval/Reasons for Disapproval <br /> 1 <br /> Anach complete plain(to IM1e County only)fur the system un paper not icss than all2 x I1 Inches in siu <br /> SBD-6398 (R. 01/03) <br />