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NSfe.m& Safety and Buildings Division County <br /> m 201 W.Washington Ave.,P.O.Box 7162 �l�..f C)(1— 0-5,/ 2- <br /> scvnsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4 gas <br /> Sanitary Permit Application State Plan LD.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information <br /> C---& olede /J. <br /> Property Owner's Name Parcel# Lot# Block# <br /> Bruce g trlvw 612?VZ96gcv / <br /> Property Owner's Mailing Address Property Location <br /> 1(0.7 C Z� <br /> City,State kaa�� Zip Code Phone Number �`• # � Section <br /> cal4r:614 i 35Z;6 (O6q`ZO/- /ZD4. (c• le one) <br /> II.Type of B ding(check all that apply) T N; R Or w <br /> VI or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use MOW / J MOO d 1 <br /> ❑State Owned-Describe Use ❑City_❑Village Township of_________ <br /> xt/1d1/ <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ANew System ❑Replacement System .❑Treatment/Holding Tank Replacement Only ❑Oth <br /> y: xisting System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List ' ?,-�ed <br /> Before Expiration Plumber Owner <br /> SI <br /> IV.Type of POWTS System: (Check all that apply) (JUN <br /> ❑Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil A.Mound<24 in.of suitable soil ■ At-Gra.- D ■ Single Pass ``s San It 1'/ <br /> Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment a • ❑i e : , • Sand Filterrrll 1/1 <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) Hea/th Op fn4/rp <br /> V.Dispersal/Treatment Area Information: - Parr�en q <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System E •. -.n <br /> 50 / q5-0 5'0 I D S�, _ <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 /> - <br /> Tanks Tanks <br /> Septic or Holding Tank I too 'boo f <br /> Aerobic Treatment Unit (� <br /> Dosing chamber b b OTl 1 b 1 ci I thef t'Lty <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 iiPfMPRS Number Business Phone Number <br /> IP M (r C ty kt u,Zip Code-7 2233 2? _ 9.?0-9 ?.51.7 <br /> Plumber's Ad " <br /> .O. �x go0 Lake Ail 1' :1 63551 <br /> VIII.County/Department Use Only <br /> �PProved 0.Disapproved Sanitary Permit a(includes Groundwater 7te lssu s „. / <br /> pproved , o Stamps) <br /> Surcharge Fee —724- t1,{ P , 5❑Owner Given Reason for Denial g ) �7 �f�a' i <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 111 inches In size <br /> SBD-6398 (R. 01/03) <br />