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Safety and Buildings Division Cou <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> all <br /> Asconsin Madison, WI 53707-7162 Site Address n <br /> De artment of Commerce 5wis6rrA KD <br /> Sanitary Permit Application Sanitary perm Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide tna 495 /67 <br /> r 95 /6 7 <br /> be used for secondary s Privacy Law sl5. IXm ❑ Check if R 4 vision lJ <br /> I. Application Information-Please Print All Information State Plan I-D umber <br /> Property Owner's Nam Parcel Numbe <br /> s W-et fila- `-Iaprl- ori - 7 <br /> Property Owner's Mailing Address d <br /> i3 p Property Loa on (p j <br /> City.Sate � V\ I e_ tX %:S T -D N.R <br /> `� t Zip Code Phhoone Number Lot Number Block Number <br /> I, ,1 n I 1 L— I 1 1 5 a Subdivision N e CSM Number <br /> U TT l 111 (spa p J J �{ 9 s 3 - S9 b o <br /> IIJ.Type of Building(check all that apply) '7 ❑City <br /> 6& or 2 Family Dwelling-Number of Bedrooms J <br /> ❑Public/Commercial-Describe Use []Village_ <br /> wnshi <br /> ❑State Owned Nearest Road <br /> 5 Lj er <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B f applicable) <br /> A. 1 0 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Ord Existi- S stem <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Da Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 4414 Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Comtruue I 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.Dis ersaUTreatment Area Information: <br /> Design flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Ram(Gals./Days/Sq.Ft.) (Min./Inch) t)PftfL 195.50 Elevation <br /> Oso y 3 �l t ' i 9 .zs 92' <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab ire Steel Fiber Plastic <br /> Gallons Gallons of Tanks Commit Co wcted Glass <br /> — 7— <br /> TaNu Tanks <br /> Septic or Holding Tank ' - /0 m� <br /> Dosing Clamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pill tier's Sig r MP/MPRS Number B siness Pborte Number <br /> osbnJ l�0sn 173 <br /> , <br /> Plumber's Address(S t,City,Sum,Zip Code) <br /> W9soa�, o <br /> VIII. Count [De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater I Dam Issued I suing a Signature camps) <br /> Surcharge Fee) <br /> C1Owner Given Initial Adverse <br /> Determination /V( 1pj7 W <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> E�ISTy4.Yy �s A✓A&15 %b 96 /i&-UOLW IQ,�tz T i usfn.lrwfi�t o f S,e r cLbsot . n C r <br /> Attach complete plant(to the County Drily)for the system on paper not less tWn 5112 a 11 inches ins e <br /> SBD-6398 (R. 05101) <br />