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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 &&E, <br /> Nvisconsin <br /> Madison, WI 53707-7162 Site Address p <br /> Department of Commerce �3�U iQ <br /> " <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide �� ��� <br /> Check if Revision <br /> may be used for secondarypurposes PrivacyLaw,s15. 1 m ❑ <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> 2112�_334 <br /> Property Owner's Name Parcel Number <br /> Property Owner's Mailing Address 1 r ./ -�r,C7 Property Location <br /> 55 I fl �1 I�5' 3'/» S 7-4 T 41D N. R 14 <br /> City,State Zip Code <br /> �7 Phone Number n^ Lot umber Block Number <br /> �,y, �0 fJ �1�� _+7,�v(9 Subdivision Name CSM Number <br /> ✓G�L'K JET 7 W LR KC MCKer17�El t! l`1 P.f 35-- <br /> II.Type of Building(check all that apply) ❑City V t ��f <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms ❑VIla e <br /> B <br /> ❑Public/Commercial-Describe Use ownship i <br /> ❑State Owned Nearest Road j <br /> III. of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. IsatiJVew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition m For County use <br /> S st, I Tank.Only Exist'Existim 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 rise) <br /> 44 ❑ Nan-Pressurized In-Ground 219-Mound 47❑ Sand Filter 50❑ Constructed Welland <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 /> 45'° 4r0 504 ``— /oo- Z /ez.Z- <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Glass <br /> Gallons Gallons of Tanks Concrete Constructed <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank ,lift _ Q <br /> 0 �29AW <br /> Dosing Chamber W DD <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> � �v ,�s A-= z- sSs i 71' 46- 417 <br /> lumber's Address(Street,City.State,Zip Code) <br /> 27 710 o }4w �K _45406 43-3 <br /> VIII. County/ artment Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A en ignature N Stamps) <br /> Su araec <br /> [IOwner Given Initial AdverseDeterminationWtt��� e <br /> IX. Conditions of Approval/Reasons for Disapproval 7 <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br />