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Safety and Buildings Division County p <br /> 201 W.Washington Ave.,P.O.Box 7162 D et e n e t f <br /> Vscvnsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.Number `�' <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(I)(m) Project Address(if different than mailing address) (� <br /> qqa <br /> I. Application Information Please Print All Information W2G�7�� Tl'ly' <br /> Property Owner's Name DA Parcel# Lot# Block# <br /> Fool 'dk ih S <br /> Property Owner's Mailing Address Property Location <br /> N7S-67 60 V- F N33 <br /> '/., SL- �, <br /> City,State Zip Code Phone Number Section <br /> River Falls wt f`fodJ 76S- �L�O� /00/l (circle one) <br /> R.Type of Building(check a6 that apply) T 40 N; R-17E o4 <br /> IX 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> El State Owned-Describe Use ❑City ❑Village ISTownship of Urtl Ort <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 9 New System ❑ Replacement System y ep y ❑ Treatment/Holding Tank Replacement Only El 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 /> X Non-Pressurized In-Ground ❑ Mound>24 in,of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Welland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter Cl Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(st) System Elevation <br /> Llf7J • 7 643 Is, q$' C?X.0 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks L <br /> Septic or Holding Tank /COQ /00(J SrE,pW <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> *,ac h`o kin JfJ,-)t- :S/ -7/6= 866- 4ls7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 47760 H. If- W�,dsfrt- W- _5-9r?3 <br /> _VJII.County/Department Use Only <br /> proved ❑Disapproved Sanitary PermitF e(includes Groundwater Date Issued Issui Agent Signature(No Stamps) <br /> Surcharge Fee) ^ 'O_1�� � <br /> ❑Owner Given Reason For Denial Q/ `tJ <br /> IX.CAw <br /> onditions of Approval/Reasons for Disapproval �V� <br /> ��UI'I� Jug Ji l <br /> I� OCT 1 3 2003 <br /> r <br /> B R <br /> Attach complete plans(to the County only)for$pgil@INIGaper not less than 81/2 x 11 inches 1n sin <br /> SBD-6398 (R. 01/03) GlJIV 11V17 <br />