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Safety and Buildings Division County <br /> �� m 201 W.Washington Ave.,P.O.Box 7162 �h'>Q. -. 077 <br /> tsconSIf Madison,WI 53707-7162 <br /> (608)266-3151 Sanitary Permit Number(to be filled in by Co.)Department of Commerce )- j5'ik4P - <br /> State Plan:p Number <br /> Sanitary Permit Applicati n ( <br /> In accord with Comm 83.21,Wis.Adm.Code,personal informs you pprovtdd <br /> may be used for secondary purposes Privacy Law,s15 lxm)r - Project,Add (if different tfan mailing address) <br /> I. Application Information-Please Print All Information I ' MAR 1 6 2;, W--s--s+f- L n. <br /> Property Owner's T erne ; <br /> Prope¢y Location <br /> WAyv t 4 TrAty {' t-rygretSoyi C 1O co EL t Ql2h, <-f .T - E.� ''4 NE �% Section <br /> Property Owner's Mailing/Address _ r L r <br /> Pte' .-. .. 'T N lit I\ E <br /> a651 C-u.lrtykr -- <br /> City 1 State Zip Telephone Parcel I <br /> (r {r a i r■ WI 5 5 c i 1.7 o12--CG11-3DI"t o I- 3 <br /> Type of Building (Check all that apply) Subdivsion Name/,CSSM ti Lot# <br /> �: 1 or 2 Faintly Dwelling-Number of b SC�1tkS1,. k`�J"June ko I <br /> ❑ Public/Combtercial-Describe Use ❑ City ❑ Village )1:I Township of <br /> ❑ State Owned-Describe Use _ t5NSfia1 <br /> III. t: (Check only one box on line A. Complete line B if applicable) <br /> ew Sys ❑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.Type of POOTS .,;,,co" 1 i r, . , ,ply) <br /> ❑Non-Pressurized In-Gro d $Mound>24 in.o uitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter <br /> ❑ Constructed Wetland ❑ ' - . '- • : .■n' ❑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.Dis.ersallTreatment Area Information: <br /> :.,_:- i-..) Design Soil Appl Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> (ate 1•a loSC) 4003 .5A- 0.4 Isikk <br /> . . ank Info Capacity in Total No. Manufacturer Prefab Site Steel Fiber Pla- <br /> Gallons Gallons of Concr Con- Glass stir <br /> New Existing Units street <br /> Tanks Tanks <br /> CZZI Holding Talc IZ&r I2ec z Meade. X <br /> Aerobic Treatment Unit <br /> Dosingtbamber (0S0 --- to5D 1 r- X <br /> VII.Responsibllty Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MWMPRSW No <br /> fmccrcw V1- Mein-c 1v "YV 1 1415 <br /> Plumber's Address(Street.City,State,Zip Code Phone Number(Daytime) <br /> 1 J• K iu i e e,, NI 53581 <br /> VIII.County/Department Use Only <br /> Approved (3 Disapproved Sanitary Permit Fee(Intl Date Issued Issuing Agent Signature . )' <br /> Owner GW Surcharge <br /> Reason for Denial ��0 +3/��0 t �itrrp..� i/li 1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> if, <br /> / <br /> Attach complete pis(to the County ordy)for the system on paper not less than au2 x 11 inches in size <br /> SBD-6398(R. 1/03) <br />