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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7082 v r ylt <br /> Visconsin Madison,Wi 53707-7082 Sno ary Permit Number(to be filled in by Co.) <br /> Department Of co (608)261-6546 �f �/_ <br /> mmerce 612. 1 <br /> Sanitary Permit Application Sae Plan <br /> L°vNa ((� <br /> In accord with Contra 93.2 1,Wis.Adm Code,personal information you provide V / <br /> may be used for secondary purposes Privacy Lewyst5'04 1)(3 a�? Project Address(if different than mailing address) N <br /> 1. Application Information-Please Print All Information l( / <br /> ,(Agfc/a,b /1Dpabs3 4: f DL <br /> Pro Own 's Nam< , 837'j ,Tpdy Daae: Sat/!Jr Parcel# Loll Block# <br /> IIT k ,� sraa. MN ssofb oa q o oa and `1 <br /> Property Owna's Mailing Address Property Location <br /> Q66s Ih r(,Aa�� 1Z� s <br /> _'/.. '/.. Section <br /> City,State Zip Cade Phone Number <br /> QA1 /y(/i�'� �y <br /> bk'e (,J� 5-LIV50 —1ySY� 7� TSN: R curl' Je) <br /> II.Type of Building(check a6 that apply) ` <br /> Subdivision Name eexr�11" <br /> a <br /> VE or <br /> Lor 2 Family Dwelling-Number of Bedrooms <br /> ❑Public/Cotnmeroiai-Describe Use lAtfU w1i -J Ii-t T 1 )J <br /> ❑Stare Owned-Describe Use ❑City_❑Villapap*ownship of SLO /1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ PFrmit 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 /> 91-Non-Pressurized hl-Ground ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑Pressurized hr-Ground ❑ Holding Tank ❑Pest Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil lication Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 30`J 4 a� q53 °�S. 00 <br /> VI.Tank Info Capacity in Total Number Manufacturer PrefabSite Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Cowintered Glass <br /> New Existing <br /> Tanks Tants <br /> Septic or Holding Tank I J -7 0 LJ 1 C r <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undenign assume spoasibitity for iinitallation of the POVITS shown on the attached plans. <br /> PI 's Name(Print Plumber's S' tore RS Number Business Phone Number <br /> a� c�f-Ck 5 <br /> c a3so lis" -L)S00 <br /> l <br /> Plumber's Address(Street,City,S Zip Code) <br /> r 5-SI q (U,5 u1C1( 04- S ou ✓cam W, 5 001 <br /> VVI.County/Department Use Only <br /> Approved ❑ Disapproved Sanrmry Pemut Fee(includes Groundwater Date Issued Issuin t Signature mps) <br /> Surcharge Fee) �trOtyy <br /> ❑Owner Given Reason for Denial p� % 1(J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for tae system on paper no less than 81/2 x 11 tocha In sire <br /> SBD-6398 (R. 08/02) <br />