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Safety and Buildings Division County J <br /> Visconsin 201 W. Washington Ave.,P.O. Boz 7162 <br /> Madison,WI 53707-7162 Site Address <br /> Department of Comme ce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 81.21,Wis.Adm.Code,personal information you provide C Q <br /> Check if Revision <br /> my be used lot secondary purposes Privacy Law,sl5. IXm ❑ �5�43 <br /> I. Application Information-Phase Print All Information 43 State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> 4 z;�© eE- &L ©,z I - 4 moo <br /> Property Owner's Mailing Address /Property Location <br /> �3$ A?101t? �L 1_7_ u:ST�O N.RIy <br /> City.State Zip Code e Number Number Hlock Number <br /> /PNG/nt/; /`cvC PhomLot <br /> Subdivision Name CSM Number <br /> II.Type of Building(check all that apply) ❑City <br /> T ' or 2 Family Dwelling-Number of Bedrooms_ �. ❑Village <br /> ❑Public/Commercial-Describe Use owmhi -e <br /> ❑State Owned Nearest Road <br /> DT," <br /> M.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A' 1 ❑ New 1 2)0 Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Oil ExistingSystem <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Dam Issued <br /> IV.Type of Permit: (Check all�hat apply)(numbering scheme is for internal use) <br /> 44,X Non-Pressurized In-Ground 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-Gude 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dia ersaUTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Ram System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) 5— Elevation <br /> VI. Tank Info Capacity In Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Ea' mg <br /> Tanks Ta s <br /> � HoW(ng Tank <br /> lee 6_ <br /> ,412.12 <br /> am x <br /> VII. Responsibility Statement- �,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu is Name(Print) PI r' Sigmm MP/MPRS Number Business Phone Number <br /> til/ �l7iri/ ;2,25q/ 7 71!5,- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VI. Count <br /> De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A Sigmmre amps) <br /> Surcharge Fee) <br /> ElOwner Given Iridal Adverse <br /> Determination <br /> U. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than al/2 a II inches io she <br /> SBD-6398 (R. 05101) <br />