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1 � ArjI i� lip [j Sa ty�d ings Division County <br /> V /V 1I V u J J ' .`._-26-1-`W:-Washittg A e.,P.O. Box 7162 i n I. <br /> i���Di�Si Madison, 5 07—7162 Sani jPermit Number(to be filled in by Co) <br /> i Department of Comme� _�. <br /> JUL 2 5 2001 (60eb X151 Vas <br /> State Plan I.D.Number <br /> Sanitary Iermit Application <br /> In accord with Comm 83.21,Wis.(, m;;G ,fit 9li j ff tion you provide <br /> may be used fir secondary pipenpesirmfRbfw,s15.04(IXn) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information art TZtot .1. -• <br /> Property Owner's Name Property Location <br /> - m &ofd 004 COYtSfrtte*)oh i- Re at EsTeite, 5E '% NE % Section (o <br /> Property Owner's Mailing Address T 7 N R 8 E <br /> i016 Atmer 'Dr. <br /> City State Zip Telephone Parcel I <br /> Ve-rmtt IN 53933 <br /> Type of Building (Check all that apply) Subdivsion Name/CSM# Lot# <br /> 1 t 1 or 2 Family Dwelling—Number of bedroo . S.44-11¢,i- 12 vise EstaTes. to <br /> CI Public/Commercial—Describe Use - ❑ City ❑ Village I!'Township of <br /> ❑ State Owned—Describe Use Mme Ct.f <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. E''New System ❑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 /> W.Type of POWTS System: (Check all that apply) <br /> l2 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 ❑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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> .¢ k5D0 l,Si2 91 0i 95.01 <br /> VI.Tank Info Capacity in Total No. Manufacturer Prefab Site Steel Fiber pia_ <br /> Gallons Gallons of Conn Con- Glass stic <br /> New Existing Units struct <br /> Tanks Tanks <br /> Septic 91-44eictiag-Tank vex" — 1200 i MEADE • y <br /> Aerobic Treatment Unit <br /> Dosing Chamber eCX, — i 1 , • K - - <br /> VIL 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 MP/MPRSW No <br /> &YMCA", w Me.mv4h&1 L '''11se— 1.v . -1'1,-, 220165 <br /> Plumber's'Address(Street,City,State,Zip Code Phone Number(Daytime) <br /> (i3 C Ct-(. 11.. v.rui M 1 WI 5 "7 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(incl Date Issued Issuing Agent Signature(N s) <br /> / Surcharge Fee) r `� <br /> ❑Owner Given 7 ---. /31�JO Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> Check .1D 3YO.19 D dT 27133 ' <br /> SBD-6398(R.01/03) <br />