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Safety and Buildings utvtstoty <br /> n coun <br /> ��sconsin 201 W. Washington Ave., P.O. Box 7162 akrr <br /> Madison, WI 53707-7162 Sise Address �� —�--- <br /> Department of Commerce tL7.570 St`..�e Cafe X�Q <br /> Sanitary Permit Application Sanitary Permit Nwneer <br /> In accord with Cornet 83.21,Wit,Adm.Code,personal information you provide <br /> may be used for secondary purposes privacy Law 15. 1Hm ❑ Check if Revision <br /> L Application Information-Please Print All Information ��s3 State Plan I.D.Number <br /> Progeny.Owner's Name ••LJ Parcel Number C�end(•tne) GSM v 1 <br /> Lc-S71ty a Qetti AFFsIeOf Oat-1�3 —Oo� <br /> Property Owner's MaOing Address Property Location <br /> tis N. f/, ti sr. Gov E • COT a <br /> City,Sate :r,p 'A u-S 33 T 90 N,R 16 Phoon Number Lot NumbBick NumberAzmd&/PA LtJ Subditnr+uoNune CNumbe <br /> - <br /> s6 <br /> II.Type of Building(check all that apply) <br /> 91 or 2 Family Dwelling-Number of Bedrooms � ❑City _ <br /> []Village <br /> ❑Public/Commercial-Describe Use <br /> ❑Sate Owned KITowmhii 0001,14..cp _ <br /> Nearest Road n <br /> ,2 -&,<� <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.Internal use). Complete line B if applicabh) <br /> A. I If New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tack Orth, <br /> Existio S nem <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Dare Iuued <br /> [V,Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 A Non-Pressurized In-Grouod 210 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 Unit 49❑Recirculating 30❑Other <br /> V. Dis ersaUTresi ant Area Information: <br /> Design Flow,(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Foul Grade <br /> Required Proposed Rau(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site <br /> Gallons Gallons of Tanks Seel Fiber pl. ;tic <br /> New existing Concrete Constructed Glass <br /> Tams Tanks <br /> Septic or Nolding Tame BOO - 800 <br /> Dosing Clamber 1 .S�'✓ �' <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for install lion of the POWTS shown on the attached phase. <br /> Plumber's Name(Print) Plumber's Signature MP/h1PRS Number Business Phi Number <br /> Plumber's Address Direct,City,State,Zip Code) <br /> J 7760 f/ti 3S webstr 6e/-r Sr/ <br /> VIII. Count /De artir Use Only <br /> Approved ❑ Disapproved Sanitary Pemtit Fee(includes Grw idwatcr Date(slued Iswing a igmture o San ps) <br /> Surcharge Fee) ���7 <br /> ❑ Owster Given Initial Adverse 4i' �50 y v <br /> Detennbudon 'tf <br /> I7C. Conditions of Approval/Reasons for Disapprbvat <br /> Attach complete plans(to the County only)for the system on paper not less than Si/2 T, itch-;n siae <br /> SBD-6398 (R. 05/01) <br />