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Safety and Buildings Division County <br /> 201 W.Washington Ave., P.O. Box 7162 <br /> `isconsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce btQ fie Lake /Zr� <br /> Sanitary Permit Application <br /> Sanitary Perm[Number <br /> �7zzi3 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> my be used for secondary purposes Privacy Law,sl5. 1 m <br /> I. Application Information-Please Print All 111formation State Plan I.D.Number <br /> IrDU-4 <br /> Property Owner's Name Parcel Number 701Y.- -Z t 0 m2- Off.-3qO z�a <br /> J)av� A oe,15r a Y1 - <br /> Property O'wner's Mailing Address / �j �/ Property Location p (L <br /> e ,e LItiF L: /CDI�. 'A Sf:S ill T3O N.R /T E <br /> City,State FCodoPhone Number Lot Number Block Number <br /> V GLiDy/i <br /> �. 1-6r�Ir tP� �•�, y D / / �`5 —�a Subdivision NameNum <br /> V/-? O <br /> II.Type of Building(check all that apply) ❑City <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village <br /> ❑Public/Commercial-Describe Use <br /> ownship e?LJ t <br /> ❑State Owned Nearest Road /' ®� <br /> e 7>` C L- <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A' I-&New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> system 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,g Non-Pressurized In-Ground 2111 Mound 47❑ Said Filter 50❑ Constructed Wedand <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pus 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) p3.--YS Elevation <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 MOO /COO U t <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installs oa of the POWTS shown on the attached plane. <br /> Plumber's Name(Print) Plumber's Signature M P Number Business Phone Number <br /> -- <br /> U-3/, //; e �� 7f-M _& ;.503/ '7/S- �H� -3f/93 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1�/A//7 ea4, r,� k0 . <br /> VIII. Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing em nature mps) <br /> Surcharge Fee) r <br /> ❑ Owner Given Initial Adverse q};�0 4O /2-0 7_.ntL r <br /> Determination t!Y W "l <br /> IX.Conditions of Approval/Reasons for Disapproval 1-7 <br /> Attach complete plain(to the County only)for the system on paper not bus than$1/2 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br />