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Safety and Buildings Division County G <br /> ` <br /> 201 W. Washington Ave.,P.O.Box 7162 6�-Ne <br /> isconsin Madison,WI 53707-7162 Site Address <br /> De artment of Commerce -41 7.04 Z rygy <br /> Sanitary Permit Application Sanitary Permit Number <br /> / / <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide Check if Revision / 0 <br /> rim be used for secondarypurposes PrivacyLaw,s15. 1)m ❑ <br /> I. Application Information-Please Print All Information Sate Plan I.D. Number W <br /> Property Owner's Name Parcel Number <br /> CO%~N bza Rzzs 03 zV o <br /> Property Owner's Mailing Address Property Location <br /> 96 -o �l2'1 �T t� S 3Z T y(7 N,R /5 E <br /> City,Sate Zip Code one Number Lot; ober Blocck_ <br /> kNumber <br /> Subdivision Name CSM Number <br /> itivto /%N 77 ay /5r qvo ro -r6FFR,Fs <br /> II.Type of Building(check all that apply) ❑City <br /> 9 1 or 2 Family Dwelling-Number of Bedrooms 3 <br /> []village <br /> 11L/ <br /> Public/Commercial-Describe Use ®Township ©RFig <br /> AA <br /> ❑Sate Owned Nearest Road <br /> (nta, 4. {a/v"A. <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B 17 applicable) <br /> A. 1 ® New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> stem I 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 91 Non-Pressurized In-Ground 2111 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.Dis ersat/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.F[J (Min.Anch) Elevation <br /> y54 �y2 648 — 04(94(9 <br /> 173.5- 14575- <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 or Holding Tank <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 MP/MPRS Number Business Phone Number <br /> e- }W-p /SI 22S$S 44S7 <br /> lumber's Address(Street,City,Sate,Zip Code) <br /> 27-1 loo /4w �K Lfg , <br /> I. Count Department Use Ohly <br /> pproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Is Agent Signature(No Stamps) <br /> ❑ Owner Given Initial Adverse Surcharge Fee) oil <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the syrtem on paper not leas than Sl/2 x 11 Inches In size <br /> SBD-6398 (R. 05101) <br />