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Safety and Buildings Division County �� 201 W. Washington Ave., P.O. Box 7162 q 0'3– C(24 ix ,��0��,� Madison,WI 53707–7162 Sanitary Permit Number(to be filled in by Co.) (608)266-3151 Department of Commerce it- ,0 IS' Sanitary Permit Application State Plan I.D.NuQmber In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 65' U 03 may be used for secondary purposes Privacy Law,s15.04(ixm) Project Address(if different than mailing address) I. Application Information–Please Print All Informationi` a`=— TA— Proper tty Owner's Name t l& M "'•'-" i• 3 fi r` G�.Q.r N '% S ' •'h Section 10 Property Owner's Mailing Addr T N R 'I E 7) C\iI frolr. - )r City State Zip Telephone Parcel# f)(Z_– two-I- 3 0 - (00S2-6 5. 4 e,.-,r.. 1 14 tt>i A r-- — ''.......i..r_-.:',dba•p!_•.-.-.-z--...--z-..--;........ Type of Building (Check all that apply) •4 uubbdivsion Name/CS , # - 5 # `e 1 or 2 Family Dwelling—Number of bedrooms �:, T�✓r o(4S ,�;��r_- 5 a ❑ Public/Commercial–Describe Use ❑ City ❑ Village g Township of ❑ State Owned–Describe Use Q t,S 10 ' III.Type of Permit: (Check only one box on line A. Complete line B if applicable) ��22 A. ,tew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ •• Modification to Existing System B. ❑`Permit Renewal 0 Permit Revision ❑Change of ❑Permit Transfer to N- L' - i Pam;Number and Date Issued Before Expiration Plumber Owner _ ,t 1 �\, IV.Type of POWTS Syst• 1. –'r. ,,k all that app ‘� L ❑Non–Pressurized In-Groun• ►' Mound>24 in.of suitable soil ❑Mound<24 in.of suitable.oil At-GntillY p§jngle Pass San ilter ❑ Constructed Wetland ❑Pressuri -• In-Ground U olding Tank ❑Peat Filter ❑A ••is T �, Unit ❑Reclfir•,'tf f',g Filter ❑Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pt ❑O�er( jit • 111 V.Dispersal/Treatment Area Information: � `'j '' „\ / Design Flow(gpd) Design Soil Appl Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Propbsel (sf)- ; ;Sysi Eleva on t - o � s 7s ° use - I t S.". VI.Tank Info Capacity in Total No. Manufacturer Prefab Site el Fiber Pla- Gallons Gallons of Concr Con- Glass stic New Existing Units struct Tanks Tanks isle?'^,. Holding Tank I f_SO /69 . ' f' Aerobic Treatment Unit 1, Dosing Chamber /(000 /G°° _ / peck F VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached pla, Plumber's Name(Print) , 1 Plu gnatu MP 'RS W No 4 i- L Wry k- 7 124.(io 7 Plumber's Address(Street,City,Stag Zip Code Phone Number(Daytime) t)Lt 4b' '°1 CI 44*,4(,s /J S3y2,--- 1.. .63. ( / Nlit.County ent Use Only ■ Ar� Approved 0 Disapproved Sanitary Permit Fee(incl Date Issued GW Surcharge Issuing Agent Signature(No S �� \ ❑Owner Given ) Reason for Denial 1,07o e.-/-/-10.3 0_ 4.7�, A .,- IX.Conditions of Approval/Reasons for Disapproval �..-- b �07 /2 r/i N 72_, 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)