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Safety and Buildings Division C°u°e 1 <br /> 201 W. Washington Ave.,P.O.Box 7162 1 JC L1r Y�e�-T <br /> NVisconsin Madison,Wl 53707—7162 Site A <br /> Department of Commerce G� <br /> Sanitary Permit Application Sanitary Permit Numbe461096 <br /> r �G� <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide " t ✓ /0 /9 6 <br /> may be used for secondaryPrivacyLaw,s 5. 1 m C1 Check if Revisi [ <br /> on <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> 0 <br /> Property Owner's Name (61 Parcel Number <br /> U( e flJ N �5 oS Io0 <br /> Property Owner's Mailing Address Property Location <br /> 01 1 — \\ v r ;1 „ tl.- r CEO N 1 (A,)) <br /> City,State Zip Code Phone Number t Number,, Block Number <br /> Subdivision Name n CSM Number <br /> � 56730 �tf- �3790 M 4JA <br /> II. Type of Building(check all that apply) Ocity <br /> C7 1 or 2 Family Dwelling-Number of Bedrooms ovillage <br /> ❑ Public/Commercial-Describe Use ❑TowruhiPIL Ck S <br /> ❑ State Owned Nearest Road <br /> M. Type of Permi(: (-Check only one box on line A(numbering scheme for interval use). Complete line B if applicable) <br /> A. 1 11lkf New 2 Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem I Tank Only I Existing stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> l <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44`KNon-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed W,edand <br /> 22❑ Pressurizzd In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line I <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.FL) (Min./Inch) n 3 a /1 Elevation U <br /> H50 x,43 (� 91 — "�� !Y a 2 q'' <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Sim Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tula Tank <br /> Septic or Holding Tank _ <br /> Dosing Charnbcr <br /> VII. Responsibility Statement- I,the undersigned,assus a responsibility for Installation of the POYM shown on the attached plats. <br /> Plumber's Name(Prim) Pl r' Si MP/MPRS Number Business Phone Number <br /> ( rAi �� a� 5 (_035-k� <br /> Plumber's Address(Street,City,Stam,Zip Code) <br /> IP 0 - �6� SD o 6 N-e,- W11 5 <br /> VIII. CountyfDeparl3nent Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dam Issued Issuing AS t re(N s <br /> Surcharge Fee) <br /> C1O <br /> Owner Given Initial Adverse 0 50 2rJ <br /> DDeterminationrmirmtion <br /> IR. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)rot the system m pupa not less than 8111 a 11 Inches in size <br /> SBD-6398 (R. 05/01) <br />