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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> Asconsin Madison,Wl 53707 -7162 Site Address <br /> De artment of Commerce iaa <br /> Sanitary Permit Number <br /> Sanitary Permit Application lul In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision + 5 2 7 <br /> may be used for second purposes PrivacyLaw,s15 1 m <br /> I. Application Information-Please Print AB Information State Plan I.D. Number <br /> Az& 59.56 _ <br /> Property Owner's N�" / / Parcel Number <br /> 6q0-355 -DI- eC:) <br /> Property Owner/'s Mailing Address Property <br /> Property Location C �j J� �/ <br /> Y6"7� /J l s���rem /� r/ W %/U fc.)S6:S T -??N,R /d E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> H.""Type of Building(check all that apply) ❑City <br /> ,a{to, t or 2 Family Dwelling-Number of Bedrooms 1 - ❑Village <br /> I _ <br /> blic/Commercial-Describe Use /� y — wnship 4)% �//¢�S �j¢-•✓� <br /> l❑ State Owned Nearest Road <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 ew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <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 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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 GradeAcquired Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> / "?p7o , 7 — 9 y, S '�F 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 I Tanks <br /> Septic or Holding Tank Poo I <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(p t) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street.City,State,Zip Code) <br /> Igtr— <br /> VIII. County/Department Use Onl _ <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater =;Datc Issu' ge Signature tamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial AdverseDetcrnumvon l9 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete pima(to the County only)for the system on paper not lees than 81/2 x 111nehn to size <br /> SBD-6398 (R. 05/01) <br />