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Safety and Buildings UIVISIdn county <br /> 201 W. �}- <br /> ar Washington Ave., P.O. Box 7162 6cr <br /> r. n 2 1 <br /> `�sconsrn Madison, WI 53707-7162 Site Address nn 11 <br /> Department of Commerce SfAe, <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide ❑ Check if Revision (( �i U L. <br /> 4,z,2 ,2 e n <br /> ma be used for second s PrivacyLaw, 1)m <br /> 1. Application Information-Please Print All Information g State Plan LD. Number <br /> Property Owner's Name Parcel Number <br /> ,Twl DtAq-ehe- oi,4A -of-3aa <br /> Property Owner's Mailing Address Property Location <br /> 01 // 0.4/Cf e 40- 'A 'f:S 2/ T 3g' N, R <br /> City,State Zip Code Phone Number Lot Number. Block Number <br /> Subdivision Name CSM Numtx <br /> F &-Our e M Al S—S 3y7 _ <br /> IL Type of BuBd(ng(check all that apply) Dory _ <br /> la I or 2 Family Dwelling-Number of Bedrooms `T ❑Village _ <br /> ❑Public/Commercial-Describe Use OTownsbip La X0//E7ie- <br /> ❑State Owned Nearest Road L <br /> P wy 7O <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. 10 New 1 2,& Replacement System 3 ❑ Replacemem of 6 ❑ Addition to For County use <br /> System Tank Ord ExistingSystem <br /> B. ❑ Check if Sanitary Permit Previously Issued Pemur Number Date Issued <br /> IV.T(ype of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 449'1Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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 ersal/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.nnch) 90k ul Elevation <br /> 6600 Sr7 . 7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Siecl Fiber Pit,;tie <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank /. 00 <br /> Dosing Chamber 7S0 7 <br /> J: <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plmns. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> /pie/r /nS /c?�� /� S8s / 7/S- F66- 91,5-7 <br /> Plumber's Address Street,City,Sate,Zip Code) <br /> AJ77,oa t/,Y 3s� l r/e6si�� Lr/� � 'i7 <br /> VII Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes GrouMwater Date Issued Issuing Age nature(No I ) <br /> Surcharge Fee) <br /> C1Owner Given Initial Adverse ,(T nC,t�✓ /I/viw�L' <br /> Determimdon Z� /✓V n'LO J <br /> M. Conditions of Approval/Reasons for Disapproval <br /> Attach mmptete plats(to the County only)for the system on paper not less than 8112 s 11 inches In rise <br /> SBD-6398 (R. 05/01) <br />