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Safety and Buildings Division County <br /> Nvisconsin <br /> 201 W. Washington Ave.,P.O. Box 7162 Ajem Y.Madison,WI 53707 -7162 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Permit Number 423770/ �7/� <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 4z 3 7/� <br /> may be used for secondarypurposes PrivacyLaw,sl5. 1)(m El Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number yj <br /> Property Owner's Name Parcel Number W <br /> Pawl 7-110hiAjo tj � 4-11'g Ot .7_4 <br /> Property Owner's Mailing Address Property Location I <br /> / / y f /"Arlt y/MV11]t G /U ti ,y:S T ft N.R <br /> City,State Zip Code Phone Number Lot Nu her Block Number <br /> Subdivi 'on Name CSNi Number <br /> /9nok h'1 N. SS3o� 7tf3— �Fd7—S17�t <br /> H.Type of Building(check all that apply) ❑City 1 <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 <br /> ❑Village <br /> ❑ Public/Commercial-Describe Use <br /> ❑State Owned �I'owtlship SGO'1/F" i <br /> Nea st Road oayy�� <br /> ICL <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 121 New 2 ❑ Replacement For County use <br /> p System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank Only Existing System <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Welland <br /> 22❑ Pressurized In-Grourd 41 El Holding Tank 48 El Single Pass 510Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) gsrs^ Elevation yg <br /> 4-0- 0/009 4 4 ' .501 <br /> I S70 97 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> ffewExatmgSeptic or Holding Tank Dosing ChamberO <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature,,.,,,,. MP/MPRS Number Business Phone Number <br /> �*v,v ,w_s - 2zS$S 1 'SIS g66- 4157 <br /> lumber's Address(Street,City,State,Zip Code) <br /> 2.7 7 (o o 4,w 35 <br /> VIJI. CountyDepartment Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu' A t Sig a(No Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse � j� 6//��D--�� _ <br /> Determination 1,PZ i <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> CS'r )NO1CArsoC3) 5T72tra)tr 611tv(Z1J4< ,w ik?V .V ; ,l, WA 40YI-69 4KA§l <br /> P6A, Pk%%f CbXU evs0(k4­# A44Y 6, 0 1) /46 r, 110160E k,M C (1) OX*r"2E. <br /> Nw, Vet(fY 61 rtes "*_r1tna <br /> Attach complete pians(to the County oily)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 05101) <br />