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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 4 <br /> VVisconsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce �F ✓✓ S <br /> Sanitary Permit Application Sanitary Permit Number <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision 4;Z3 7e9 (� <br /> may be used for secondary purposes Privacy Law,s15. 1 m —F-_ <br /> I. Application Information-Please Print All Information 02 State Plan I.D.Number ( i) <br /> Property Owner's Name Parcel Number <br /> Property Owner's Mailing Address Property Location <br /> /v✓�t4:S l R T <br /> 32 N.1116 <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> 71 - Subdivision Name CSM Number <br /> y9' ; �r4to 5-0 63 <br /> II. <br /> Type of Building(check all that apply) ❑City <br /> OKI or 2 Family Dwelling-Number of Bedrooms ❑�.,,Villl�lage <br /> ElPublic/Commercial-Describe Use ltdTownship WfAqm <br /> ❑State Owned Nearest Road <br /> 0/d/ J— <br /> III.Type of Permit: (Check only one box on lime A(numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank OnlyExh <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV,xype of Permit: (Check all that apply)(numbering scheme is for integral use) <br /> 44 r�['lNon-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.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) Elevation <br /> foo r6 I <br /> ° Gl> m, 7 �. r/ Z, o <br /> � 9z -.21 9y� <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 /> T Tanks <br /> Septic or Hoffa c <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility r installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 71z� --T. IA- /e-A <br /> County/De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Ag t Si nature T ps) <br /> L1 Owner <br /> Fee) <br /> Owner Given Initial Adverse --03 ' <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 9 �'� aj <br /> y8 <br /> Ciq <br /> Attach complete plant(to the County only)for the system oo paper not less than 81/2 x 11 inches in size <br /> 2p <br /> SBD-6398 (R. 05101) <br /> N��CG lvT)- <br />