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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> NVisconsin <br /> (boa)266-3151 �J--3a 3 99 o18IlO <br /> Department of Commerce <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 9�U 9o/ . <br /> may be used for secondary purposes Privacy Law,s I5.04(1)(m) Project Address(if different than mailing address) ^ <br /> I. Application Information-Please Print All Information 7S'dS jho.,,lotOrt e ? Rd• o0 <br /> Property Owner's Name Parcel# Lot# Block# 1" <br /> o/d. y� d <br /> Ra+l Nendrtc�csen 3'6 o7oao <br /> Property Owner's Mailing Address Property Location <br /> 15b0 .SGCY1%G Icj y,, '/<, Section 6 <br /> City,State Zip Code Phone Number <br /> Share rs/J 6 &67- 306 (f6 l. ,jcircleone) <br /> II.Type of Building(check all that apply) T N; R_E o<W <br /> 0 I or 2 Family Dwelling-Number of Bedrooms Subdivision <br /> //Name I— (.0 CSM Number <br /> ❑Public/Commercial-Describe Use P`-"- - - �E- ( v <br /> El State Owned-Describe Use ❑City_❑VillagePgTownshipof LACkaOn <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System �'Replacement System ❑ Treatment/HoldingReplacement Only El Other Modification on to 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 A Holding Tank ❑Peat 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 Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) 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 q <br /> Septic Holding T 998 / 8 Straw• X <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 /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Roe-,-- 110,0161 S % A1.), / 7/S- 8d�o— 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J. 77(,0 A(w 4 3J- We bply, Wr SS`r`/.3 <br /> VII .County/Department Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signature amps) <br /> Surcharge Fee) �� <br /> 11 Owner Given Reason for Denial 9 <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 11 inches in sin <br /> SBD-6398 (R. 01/03) <br />