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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 I�-(N Q <br /> iseonsin Madison,WI 53707-7162 Sanitary PetmitNumber(to be filled inby Co.) <br /> De artment of Commerce (608)266-3151 <br /> Sanitary Permit Application StatePlan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 14(P 9 �8 <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 <br /> Prowner's Name ` Parcel# Lot# Block# <br /> e 1- p 701A-Z -3'NO/0-Z-Ox - lid <br /> Pr perry er's Mailinj Address Property Locatiio''n�� '' <br /> 6 V NE 1/4, �/ '/., Section !D <br /> City,State Zip Code Phone Number <br /> 72T ) (circle one) <br /> .-7 T N; R-LE or W <br /> II.Type of Building(check all that apply) <br /> KI or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use wry, <br /> ❑State Owned-Describe Use ❑City_❑Village Township ofnr�V'ry- <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. KNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification[o Existing System <br /> B. ❑ Permit Renewal ❑ 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 /> ❑ 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 q Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravekless Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <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- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu er's Name(Print Plu 's Signatur MP PRS Number Business Phone Number <br /> 1 el � l / <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z 7,7oo S ®ter <br /> VIII.Count /De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signatur o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial 1Z l.� �✓ t27 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x I I inches in sixe <br /> SBD-6398 (R. 01/03) <br />