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' f a Jaiety anti bunuttigs 1JIVISIUn •.111O1y <br /> 201 W. Washington Ave., P.O. Box 7162 LA <br /> isconsnn Madison,WI 53707—7162 Sanitary Permit Numb99yr(to he filled in by Co.) <br /> Department of Commerce (608)266-315�� JG �� 9�-7 /O5—oo <br /> Sanitary Permit i '"Ji i ll V State Plan 1.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Codt, . al information you prawns <br /> may be used for secondary purposes. Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Info a I JAN 4 2005 <br /> rt <br /> Property Owner's Name Property Location L yam" <br /> kie Ii GDI FAY1,Cterl Dane County Environmental S W V. N E <br /> Health flepartmeDt V. Section V1 <br /> Property Owner's Mailing Address — <br /> T G N R it E <br /> 21t5 VinbUm Pd. <br /> City State Zip Telephone Parcel# <br /> 9,.An .0"Gk1n2. V\Ik 53 •0 S37--0725 012-0411' IGi l-%kZ59-0 <br /> Type of Building (Check all that apply) Subdivsion Name/CSM# Lot# <br /> X1 or 2 Family Dwelling-Number of bedroom). ' <br /> N(.. -v\ ) Pad Est. cdc <br /> Ll Public/Commercial-Describe Use <br /> ❑ City ❑ Village `,>i3 Township of <br /> ❑ State Owned-Describe Use BYtS I <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 'New System ❑Replacement System ❑Treatment/I bolding 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 Lssued <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 0 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 Appl Rate(gpdst) Dispersal Area Required(sf) Dispersal Area l'roposed(sf) System Elevation <br /> (.ace I-c (oC� <br /> VI.Tank Info Capacity in Total No. Manufacturer Prefab Site Steel Fiber Pla- <br /> Gallons Gallons of Concr Con- Glass <br /> New Existing Units struct SIiC <br /> Tanks Tanks <br /> septa o Holding Tank 128(0 -- ba3/4 i MEADS X <br /> Aerobic Treatment Unit <br /> Dosing Clamber Co eL7 ws,c, 1 ;, 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 Signature 44.1'/MPRSW No <br /> - irev\I IN . MAlghc42 — 0-3• 220It,f5 <br /> Plumber's Address(Street,City,State.Zip Code Phone Number(Daytime) <br /> X513 }k-NpN-k.. V\IIVneUvee, 1\ 531-7 831-g103 <br /> VIII. County/Department Use Only <br /> PP roved ❑Disapproved nitary Permit Fcc(incl Date Issued Issuing A ent Signature(No Sla <br /> r/f <br /> Surcharge Fee) _ <br /> ❑Owner Given 1/1,0/6,s , <br /> Reason for Denial k C9Ca -• <br /> _ <br /> IX. Conditions of Approval/Re ns for Disapproval <br /> • <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size t <br /> t <br /> SBD-6398(R.01/03) <br />