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Safety and Buildings Division countyp <br /> 201 W.Washington Ave.,P.O.Box 7162 U u e Is P� <br /> isconsin Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co <br /> Department of Commerce (bog)266-3161 ,I Q5 �$ <br /> Sanitary Permit Application StatePlanI.D.NumberIn accord with Comm 83.21,Wis.Adm.Code,personal information you provide I2 /7 /I� a <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# Lot# G Block_4 _�(l <br /> /Iles /3enn0 6a9 r41J. fo — aISOO <br /> Property Owner's Mailing Address Property Location <br /> 6ov'4-- Co-r a <br /> / 36S Go. /?S . C <br /> /,, %. �6 <br /> , Section <br /> City,State Zip Code Phone Number <br /> ;,?.*0npv Wr Sy�Or ifs-6sr- ys/r T iVN; R�E(circle <br /> cre) <br /> 11.Type of Building(check all that apply) <br /> 1fIor2Family Dwelling-Number of Bedrooms d Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> EI State Owned-Describe Use ❑City_❑Village gTomship of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 9 Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification 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 Weiland ❑ Pressurimd In-Ground K 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(gpdat) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 300 p _1�00 30e 9t? 73 <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> NewExisting <br /> Tnnks Tanks <br /> Septic or Xuldms4eas c -Nb 7J'O <br /> ,4.K IA6D 7So <br /> Dasing Chamber 51V <br /> VII.Responsibility Statement-1,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 /> Plumber's Address Street,City,State,Zip Code) <br /> 7.76 O //w 93 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui A at Sign r o Stamps) <br /> Surcharge Fee) d� A 0 <br /> ❑ Omer Given Reason for Denial (p �J q,0 }{✓5 V <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plase(to rhe County only)for the system on paper not lees than 51/2:11 inches in site <br /> SBD-6398 (R. 01/03) <br />