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Visco45 Safety and Buildings Division gNubw <br /> nsin 201 W. Washington Ave., P.O. Box 7162 / ,gidMadison, WI 53707 -7162 De artment of Commerce <br /> Sanitary Permit Application mit Number � ��In accord with Camm 83.21,Wis.Adm.Code, personal information you providey9fma be used for second ses Privac Law,s15. 1 m RevisionI. Application Information-Please Print All Information .D.NumberProperty Owner's Nameer <br /> Property Owner's Mailing Address Property Location r i <br /> 01133-5,3cjx _ �/ �A:S 3,3 T YO N,F1% <br /> City,State Zip Code one Number Lot Number Block Number <br /> SbbdiwsiemName CSM Number <br /> lde�� G✓� <br /> 5_Y5�7z VA ,;l <br /> ,I,�L/Type of Building(check all that apply) ❑City <br /> X — <br /> or 2 Family Dwelling-Number of Bedrooms _ ❑Village <br /> ❑ Public/Commercial-Describe Use nship <br /> ❑State Owned Nearest Road <br /> 6 /e5 <br /> ID.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 ❑ New 2 5rReplacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank Ord Existin S stem <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 gNon-Pressurized In-Ground 21❑ 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 Ural 49❑Recirculating 3o❑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,FQ (Min./Imb) Elevation <br /> 7 , 5 <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 /> pTanks Tanks p�t <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII, Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signamre MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 130Y SYS/ 5/"Pe^j G✓45- <br /> VIII. County/De artment Use Onl _ <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing en ignature tamps) <br /> Surcharge Fee) <br /> El Owner Given htitial Adverse d/ Z50 WJ <br /> Determination �((� ��O0 (� <br /> I.Y.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(lo the County only)for the system on paper not less than 91/2 x 11 inches to size <br /> SBD-6398 (R. 05101) <br />