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Safety and Buildings Division, County <br /> 201 W.Washington Ave.,P.O.Box 7162 Olkl- <br /> S 0 <br /> C f Ifl Madison,WI 53707-7162(608)266-3151 Sanitary Permit Number be filled in by Co.) <br /> Department of Commerce 1/5).6.3-I oy-b373 <br /> Sanitary Permit Application a kcgq State Plan I.D.Num <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide w <br /> may be used for secondary purposes Privacy Law,s15.04(lxm) A Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information 2 7'7 ]��y <br /> Property Owner's Name Parcel# f T Lot# Block# <br /> Pip t3re1 + Ntalivr 05 /Zoi 2857 06 <br /> Property s Mailing Address Property Location <br /> 2Z2 Wali•pr ✓4. It/ ' <br /> City,State Zip Code Phone Number � �' Section <br /> ` l'17Dr'ie1 W� ✓5 _ t/D$^q7rj' 5Z3 T 5 N; R/Z(`E lorl#0- <br /> IL Type of Building(check all that apply) <br /> VI or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> [1 State Owned-Describe Use ❑ ity_❑Village$Townshipof A11jvj`J <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)A' ANew System ❑Replacement System .❑Treatment/Holding Tank Replacement Only r .T o•ti a% -,:System <br /> i vious Permit `�, e a i, 11 <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New 1 j ` . <br /> Before Expiration Plumber Owner dill C <br /> IV.Type of POWTS System: (Check all that apply) ''�F <br /> ANon-Pressurized In-Ground ❑Mound>24 is of suitable soil ❑Mound<24 in.of suitable soil 9 •t-Gr eO i A -"':e Pass Sand F A <br /> Constructed Wetland ❑Pressurized in-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit 14/'t t Ny• i r 1 Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) e4t <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevatio <br /> 6� _ . q I 13oa 1 Ica, Iel=0./ czs/axo <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 �r�f <br /> Septic or Holding Tank !Goo — 16th / W/j'" &'m <br /> Aerobic Treatment Unit / <br /> Dosing Chamber <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 �p 10fg/MPRS Number Business Phone Number <br /> Nt T A-.e 'r.�� T J Z233Zc 9�D-��'� �i <br /> Plumber's •.•-_.<(Street,City,State,Zip ••s f <br /> P o. Box 56,8 Lake ,'i --/L, w.-J g365 1 <br /> VIII.County/Department Use Only . � <br /> pproved ❑.Disapproved Sanitary PPermit F includes lundwater Date IssJued,/ . y1 41 . o Stamps) <br /> Surcharge <br /> ❑Owner Given Reason for Denial I e 1 o/ AV/rf rI''�'%� IZ <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 aia <br /> SBD-6398 (R. 01/03) <br />