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Safety and Buildings Division Lou°ty 201 W.Washington Ave.,P.O. Box 7162 �ly1Q 1 077 ® iSCOOSIO Madison,WI 53707—7162 (608)266-3151 Sanitary Permit Number(to be filled in by Co.)' �J 1-`t ' Department of Commerce ' lv State Plan I.D.Number Sanitary Permit Application I In accord with Comm 83.21,Wis.Adm.Code,personal informs on you rovida - may be used for secondary purposes Privacy Law,s15.04(1 Xm)I� -_ ry Project,Addrest(if different than mailing address) 1 i I i I. Application Information—Please Print All Information MAR 1 6 2(04 SSi - 1-41, Property Owner's Name Property Location Wayne J\TrAcy }k-+'rvia.0As6v► C lo 1 CO P�lkt,C�4-"-,`7- _7--- __ ; - SE1 'i. ' NE �i section 30 Property Owner's Mailing Address _______ ..- T �' N ) 11 E 851 C-elkv NAvy � City / State Zip Telephone Parcel/ Suit ?r a i n e_. WI 535cID O 2-OG11-.1-i,. (- 3 Type of Building (Check all that apply) Subdivsion Name/CSM it Lot if X 1 or 2 Family Dwelling—Number of bedr illab 3 S1,. k t/Id3 lei! ❑ Public/Commercial—Describe Use ❑ City ❑ Village jZ! Township of O State Owned—Describe Use _ 15A.Stok III. it: (Check only one box on line A. Complete line B if applicable) • New Syste ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV.Type of POWTS S el • fee . I 1 . a,ply) ❑Non—Pressurized In-Gro d .Mound>24 in.o r uitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ Constructed Wetland ❑ ' - • z . n o ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) V.Dispersal/Treatment Area Information: o ) Design Soil Appl Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) . System Elevation t0011.: 1, C laCO (003 a3 sak. ank Info Capacity in Total No. Manufacturer Prefab Site Steel Fiber Pla- Gallons Gallons of Concr Con- Glass stic New Existing Units struct Tanks Tanks C.�ep r Holding Tank 1281 — I20c, 2. megdL- X Aerobic Treatment Unit Dosing Chamber (o50 (p I v- - X VII.Responsibility Statement-I,the undersigned,assume responsibility for installation or the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRSW No AY fI W • Meahhd L _ _ ___ /L -h I Rollo W Plumber's Address(Street,City,State,Zip Code Phone Number(Daytime) , (cS iAiNN, K iw x,, W 1 53587 VIII.County/Department Use Only likApproved ❑Disapproved Sanitary Permit Fee(loci Date Issued Issuing Agent Signature s) , GW Surcharge�y i ; ❑Owner Given J !� Reason for Denial lC1 d ! b iii z "air IX.Conditions of Approval/Reasons for Disapproval 1 Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size • SBD-6398(R.01/03)