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0 <br />Artaem eovaprere pans tune Uwasty only) Torroe system a paper as uss vasa sus r r r meats s amj <br />t <br />SBD -6398 (R 01/03) <br />Safety and Buildings Division <br />County <br />201NW. Washington Ave., P.O. Boa 7162 <br />Dane <br />,wonzin <br />Madison, WI 53707 - 7162 <br />Sanitary Permit Number (lo be filled in by Co.) <br />° i)e artment of Commerce <br />2 53 (6N) 266-3151 <br />5 0 I g 3 7 <br />Sanitary Permit Application <br />Stdc Plan LD. Number <br />In wowd with Comm 83.21, Wis. Adm. Coda personal iatbrmatiaa you provide <br />may be used far swondary purposes Privacy Law, s]5-04(IX-) <br />Project Address (f &f rwt thea mailing addn ss) <br />2861 Henshue Road <br />I. Application Infortantion - Please Print AN Informatlon <br />Property Owner's Now <br />Pard # Lot # Block # <br />Scott & Cheryl Wilson <br />0610-071-8710-7 <br />Property Owner's Mailing Address <br />Property Location <br />2861 Henshue Road <br />NW y� NE s«xim 7 <br />(Sty, State <br />Tip Cade Phone <br />Number <br />Madison, WI <br />53711 <br />575-7790 <br />arraeow) <br />T 6 N; R 1 E or w <br />It. Type of Building (deck all that apply) <br />Subdivisim CSM Namber <br />121 or2FamilyDwdliog- Number ofBedraoms Convenience Restroom <br />❑Public)CommeIvial_Describe Use <br />Metes & Bounds <br />❑(StyDvmw UTowa>ship of Dunn <br />❑ Stale Owmed - DesmU Use <br />ID. Type of Permit: (Cbeck only one box oa line A. Complete Use B R applicable) <br />A' <br />❑ New System <br />❑ Replacement System ❑ 'tiratmant/Holdmg Took Replacement Only <br />❑ Other Modi&mbon b Existing System <br />B. <br />❑ Permit Reaewai <br />Before Eviration <br />❑ Pamit Revision ❑ Chsnge of <br />Plumber <br />❑ Permit Transfer to New <br />Owner <br />lid Previous Permit Number and Date Issued <br />IV. Type <br />of POWTS S Check al that <br />❑ Non -Pressurized b4imusd ❑ Mand > 24 in. of suitable soil ❑ Mound < 24 in. of sortable sod ❑ At Glade ❑ Sieger Paas Sand Filler ❑ <br />Constructed Wetland ❑ Ptessuui ed b4kuund ❑ Holding Tank ❑ Pad Filter ❑ Aerobic Treatment Unit ❑ Raarwlmlift Sad Filter ❑ <br />Recirculating Symilbetic Media Filler ❑ Leading Chamber ❑ Dnp Lina ❑ ani ravel -leo Pipe ❑ Other <br />V. Dispersairrrentiment Area Idorosatbs' <br />Design Flow (gpd) <br />Design Soil Appticatioo RaWAxisi) Dupaoal Area RogoKW (so <br />Dispersal Arca Proposed (d) <br />Sysi m Elevation <br />78 <br />0.4 195 <br />198 <br />94.0' <br />VL Task We Capacity in <br />Total <br />Number <br />Manu6dwtx <br />Prc&b <br />site <br />Stoll <br />Fiber <br />Plastic <br />Callao$ <br />Gallons <br />of units <br />Concrete <br />Constructed <br />Glass <br />New Rxbft <br />Tads Taub <br />Be*— HoMiNg Took 800 <br />800 <br />1 <br />Crest <br />x <br />Aerobic Twoutw t Una <br />DosiMCImaziber <br />VM Responsibility Statement- 1, tie asdeffAVw , awe responsibility for iautaftdm of the POW" lbws eo tie attaeied <br />Pbsrber's Name (Print) <br />Plumber's Sigo$tTre <br />Number <br />Business Phow Number <br />d 44-r .C-,v1e11-so14 <br />qev� <br />)44 <br />608S Is-�o l <br />Planba's Address (Street, City, Stale, tip Code) <br />5.28 L co ©`'G <br />VUL C!!!q2mrtmest Use <br />❑ DWffwvW <br />Permit Fa (includes Cboundwater <br />Dole Issuednn <br />t StayQs� <br />❑ Owner Given Reason for Denial <br />Sumbuye <br />(�, Q 0 <br />/ <br />l Q/V D <br />KKK <br />DL Conditions of Appreval/Reasons for Disapproval <br />NOV - 8 2GGr <br />Artaem eovaprere pans tune Uwasty only) Torroe system a paper as uss vasa sus r r r meats s amj <br />t <br />SBD -6398 (R 01/03) <br />