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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burn e-H— <br /> isconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 445(o17 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information / I <br /> Property Owner's Name D Parcel# Lot# Block# <br /> Do'l S?/am 4 01J-- 4)- /3-0(VS'DO <br /> Property Owner's Mailing Address Property Location Gov't. Lc�-F cj <br /> 3Sa 0 R IC-1l r c <br /> City,State Zip Code Phone Number '/4, Section <br /> Web j{.ems L< L Sq x3`13 715-o -7 73031�ircle9) <br /> II.Type of Building(check all that apply) T �0 N; It /S E o6V <br /> J <br /> Or1 or 2 Family Dwelling-Number of Bedrooms " Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use �oT ' 0-,rn V. _,5 3a-a, <br /> ❑State Owned-Describe Use ❑City_❑Village XTownship of LAe V! 0l'l <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A' ❑New System R lacement System y ep y ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> BList Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑ Permit Revision ❑Change of L1 Permit Transfer to New <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 ❑ 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 /> 3Q© .7 <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-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 /> R fGlc /moo /hS i` S�✓`• <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .1 7 760 IPY�w 3S WeA r1,_, <br /> VIU.Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui t Signature Stamps) <br /> Surcharge Fee) ��//�������� p/� <br /> ❑Owner Given Reason for Denial l�C�LI l� 1 J tOf 03;1 <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 size <br /> SBD-6398 (R. 01/03) <br />