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Safety and Buildings Division Count <br /> 201 W. Washington Ave., P.O. Box 7162 “I -.e._� consin Madison,WI 53707—7162 Sanitary Permit Number( be filled in by Co.) <br /> Department of Commerce (608)266 3151 5/80/0 U <br /> State Plan I.D.Number I <br /> Sanitary Permit Application 3 � �� I.D. it' 3�(.5 In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s 15.04(1)(m) t ,y24(70 Q Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information �� l V <br /> Property Owner's Name `� Property Location <br /> A c\\1 G �% "'^ ; r • 1 J ' % Pv. E— '/4 Section r;1 q <br /> Property Owner's Mailing Address <br /> T N R 1 E <br /> T ` � q n <br /> City State Zip Telephone Parcel# <br /> VCVO/...:a. W 5 5 a - O 0601 1 ._ qt,' e --D <br /> Type of Building (Check all that apply) Subdivsion Name/ S Lot# <br /> 1 or 2 Family Dwelling–Number of bedrooms `'` C,3 . <br /> ❑ Public/Commercial–Describe Use ❑ City ❑ Village ill Township of <br /> Cl State Owned–Describe Use <br /> ce_ �%b(.V{tl <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 1 iii,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.Tyne of POVVTS 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 U 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.DispersaUTreatment Area Information: <br /> - Design Flow(gpd) Design Soil Appl Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> bet , 6 G c 0 6 c 0 ID9,e <br /> VI. Tank Info Capacity in Total No. Manufacturer Prefab Site Steel Fiber Pla- <br /> Gallons Gallons of Concr Con- Glass stic <br /> New Existing Units struct <br /> Tanks Tanks <br /> Septic Ong Tank j 3 O 0 — /300 i Da t rr•c-N-i=y <br /> Aerobic Treatment Unit <br /> • <br /> Dosing Chamber .7 S L — . ")Se) I I I IL <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/MPRSW No <br /> Timothy J Jelle %1 „�. ,� , 227525 <br /> �r <br /> 1Plumber's Address(Street, City,State,Zip Code Phone Number(Daytime) <br /> 501 Commerce Parkway Verona Wi 53593 608-845-7466 <br /> VIII. County/Department Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(incl Date Issued I Issuin gen igna re(No Stamps) <br /> GW Surcharge Fee) <br /> /-'(t r 9 <br /> ❑Owner Given ,TXF> `1 <br /> i Reason for Denial 1 c A/4,-- <br /> 1X. Conditions of Approval/Reasons for Disapproval <br /> —, 94° /'9I 414 2 sal -6: (4 fT BE /eC2,4 4' Ilea4V4Y1r01 <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> - - <br /> 5131)-6398(R. 01/03) - <br />