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315 <br /> Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 b an e_ <br /> isconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 50 19I <br /> Sanitary Permit Application State Plan D.Number <br /> PP <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,515.04(1 xm) Project Address(if different than mailing address) <br /> d 43.58- <br /> (ptg7 Porrtaoyt_ Rd. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# Lot# Block# <br /> Cour-A- L.o_ .rninc3 Ce.64cr Prbl, LLc 0141 -Dg lo-033-3170 -c <br /> Property Owner's mailing Address Property Location <br /> City,State Zip Code Phone Number Otis W /S Section <br /> Q.roc cS} wl 53S3Z 60%244-36Z. , le rW <br /> II.Type of Building(check all that apply) T S N; R •1 r W <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms Si bdlvisimrliatise• CSM Number <br /> &Public/Commercial-Describe Use Day Cf�P t� � 2 9 7$9 <br /> ❑State Owned-Describe Use ) ❑City_❑Village Township of Re rice <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A" ❑New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New <br /> 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 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 /> 2.1644.6 015 2.705.0. 33 Go See, Si•1e P I wn <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 3(o0b 3 LeCO • D a'i'r o.r X <br /> Aerobic Treatment Unit <br /> Dosing Chamber 7445-0 75t i m(,L1• V <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installatiaa of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) ber's Signature MP/MPRS Number Business Phone Number <br /> Steven Tesmer 227116 (608) 837- 5297 <br /> Plumber's Address(Street,City,State, p Code) <br /> N8458 County Rd. 0, Waterloo WI 53594 - <br /> VIII.County/Department Use Only <br /> ,pproved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Iss (N <br /> Agent Signature o Stamps) <br /> Surcharge Fee)4 3!S• 0 O lL-o4 GGya.r.--1rL//her 1 Q <br /> ❑Owner Given Reason for Denial <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 z 11 inche!m 4 e <br /> ti! SEP 2 7 <br /> SBD-6398(R.01/03) <br />