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Safety and Buildings Division Count <br /> 201 W.Washington Ave.,P.O.Box 7162 OA r4*. <br /> NiNflisconsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 115D go?rt Gy— 05-11(Department of Commerce _ <br /> State Plan I.D.Nu <br /> • Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15-040 Xm) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# Lot / Block# <br /> Nol4m 3flEilL O $1 - 2'r gssC)'Cit <br /> Property Owner's Mailing A ddress Property Location <br /> 698 She is ,! Dt r j 4 A) V.,__N__----g v.., Section Z8 <br /> City,State / Zip Code Phone Number <br /> fli l47?shd LL , ea r .s..3s's9 (0 18- 839-/oio (cirele•ene) <br /> T e N; R /Z Eor"? <br /> II.Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> Nf1 or 2 Family Dwelling—Number of Bedrooms a Q r <br /> ❑Public/Commercial—Describe Use 9`9J <br /> ❑State Owned—Describe Use ❑City ❑Village EiTownship of mawl./I4 <br /> III. •e of Permit: heck only one box on line A. Complete line B if applicable) <br /> XNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> 4 <br /> B. ❑Permit R. a ❑Permit Revision ❑Change of ❑Pemit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before ration Plumber Owner <br /> IV.Trype 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 1 ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> i <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 /> &CO . V /SO _/Coo 99.Z . <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 HelAengg3nk 13a /3oo / DA/Mm t�/ X" <br /> Aerobic Treatment Unit CJ 7 <br /> Dosing Chamber 730 — '731., ! Da4,/rti ravt my X <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si•.atureL/ _ - MP/MPRS Number Business Phone Number <br /> 8-AN /4.55 s.. ; ° Z2359(/ 9Jo-99Z-6.457/ <br /> Plumber's Address(Street,City,State,Zip Cod:/ <br /> 515 L,Weo%l jw Rro, O. 5'39(.0 t <br /> V IL County/Department Use Only <br /> h •,roved ❑Disapproved Sanitary Permit a(includes Groundwater Date Issued Issui _. T , �/.•) <br /> ■ <br /> Surcharge ce❑Owner Given Reason for Denial ` <br /> IX.Conditions of Approval/Reasons for Disapproval <br />