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Safety and Buildings VIM= county <br /> 201 W. Washington Ave.,P.O.Box 7162 /J a/ �i e <br /> `wi5con C,n Madison,WI 53707-7162 Site Address <br /> Department of Commerce ills �af lZi <br /> Sanitary Permit Application Sanitary Permit Number <br /> in accord with Comm 83.21,Wis.Adm.Code,peroral information you provide ❑ Check if Revision ���O� <br /> may be used for secondary purposes Privacy law, 15. lxm <br /> I. Application Information-Please Print All Information Stare Plan I.D.Number <br /> �8 <br /> Prope Owner's NamParcel Number <br /> Property Owner's Mailing Address Property location C Cri�-�.^ <br /> 3 9"//— y31—d 110e S rA u;$ T ON,R �Y <br /> City,State Zip Code Phone Number Lot Number Bleck Number <br /> Subdwisioa-Alamo CSM Numbe <br /> M00015 ,J Vle 13 1,6 Z <br /> H. a of Building(check all that apply) �2 Dory _ <br /> Vtor 2 Family Dwelling-Number of Bedrooms []Village _ <br /> ❑Public/Commercial-Describe Use �— Ptownship SGS . <br /> ❑State Owned Nest Road, <br /> O ��, <br /> 77S <br /> I11.Type of Permit: (Check only one box on line A(numbering scheme for.internal rue). Complete line B if applicable) <br /> A For County use <br /> I ❑ New 2 ('Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> system Tank Ord Existin S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 XNon-Pressurized In-Ground 210 Mound 47❑ Said Filter 50❑ Constructed Wedand <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.FQ (Min./Inch) Elevation <br /> as Gay v/0 C) 9' 7-9&Irs 99 - 98� <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Pl; ;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 7-5'0 7S� <br /> Dosing Chamber :570U <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation or the POWTS shown on the attached phos. ___, <br /> Plumber's Name(Print) Plumber's Signatur MP/MPRS Number Business Phan:Number <br /> 74 <br /> Plumber's Address(Street,City.State,Zip Code) <br /> ,QoX ��/ iii' e.J o✓� y� �� <br /> VUL County/Department Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Age i re(N Ps) <br /> Approved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Initial Adverse U / Z 0 q <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ¢c ' z u� <br /> Attach complete plana rto the County ouly)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />