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Safety and Buildings Division County <br /> NO 201 W. Washington Ave„ P.O. Box 7162 e <br /> rseonsin Madison,WI 53707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number - <br /> In accord with Comm 83.21,Wis.Adm.Code, personal information you provide d Check if Revision 399 75C� <br /> may be used for second purposes PrivacyLaw,sl5. 1 m <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> dhoi 1.0 .41/A c e 036 71405 0_2 360 <br /> Property Owner's Mailing Address / Property Location <br /> o?/ / l tJ,4 'on1 r d/!e ael 7'r' l� 'A ti:S 30 T`fa N,R)7 <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> ,! q / Subdivision Name I CSM Number <br /> GA��v,` /� Alt), S-sd7v /s�-yb/-r�S.-�a J;A.) tCJ6Gc� P f,ahi <br /> II.Type of Building(check all that apply) ❑City <br /> ;91 or 2 Family Dwelling-Number of Bedrooms []Village <br /> ❑Public/Commercial-Describe Use <br /> ownship <br /> ❑State Owned Nearest Road / <br /> /� /9, <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line if applicable) <br /> A. 1-0 New 2 ❑ Replacement System 3 ❑ Replacement of 6 EJ Additionto For County use <br /> System Tank only <br /> 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 /> 4416on-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51❑Drip 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) Elevation <br /> / 7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic orU&WingTankda r �� �' e4_1 X <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(Pr ) Plumber's cYcSignature MP/MPRS Number Business Phone Number <br /> e_ / tVTj�I76 „� z _:;z z 7 6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6X 5/ V 5 .r'e,-J o.✓ g a <br /> VIIL Count /De artment Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Isewd Issuing A . nature(N ps) <br /> Approved C] Disapproved Surcharge Fee) -44%W Q29" <br /> ❑ owner Given Initial Adverse 2� 1 3Jvne OS , <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> R�Isivr� : aNSFEt2 Flom 5ctt,uf_j_L T /QuFSHo!-M <br /> JA)C06ASC 7o &00 GPD r✓0'''% 4.5'0 62b <br /> jcz FG v".) .xtl- 44670AR OY0 Sys M" <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05/01) <br />