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C J <br /> Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 r`1 r vN e <br /> Madison,WI 53707-7162 Site Address (1 <br /> isconsin xj <br /> De4artment of Commerce Sanitary Permit Number <br /> Sanitary Permit Application 39 5 <br /> In accord with Comm 83.21,Wis.Adm.Code,pe <br /> rsonal information you provide ❑ Check if Revision <br /> tea be used for Secoadary purposes Privacy Law,s15. 1 (m) State Plan I.D.Number AM- <br /> 1. Application Information-Please Print All Information <br /> Parcel Number <br /> Property owner's Name digy,I l�8 � o/I— OQ <br /> Z't 11 �1 G;W1 e c NOV. "�(0. Property Location <br /> Property Owner's Mailing A ress 18 T^� <br /> 400 Dc r � ISO R k 4:S <br /> CCS �fl Number ock Number N,R <br /> ip Code Phoma Number Lot S -F 3 <br /> City,State <br /> �e CSM N r <br /> )n , SC a Q1o4s CSI•'t4 a0,(a 1%J61. III P' )�4 <br /> � l 9 <br /> U.Type of Building(check all that apply) ❑City <br /> 3 <br /> 1 or 2 Family Dwelling- <br /> Plumber of Bedrooms ❑village <br /> ❑ <br /> public/Commercial-Describe Use Township <br /> Nearest Road W74.1 <br /> ❑State Owned j r C <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> For County use <br /> A. 1 ❑ New 2-gReplacement System 3 11 Replacement of 6 ❑ Addition to <br /> Tank Oniv Existing S stem Date Issued <br /> S stem permit Number <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) 50 El constructed Weiland Mound 47 11 Sand Filter <br /> 44Non-Pressurized In-Ground 51❑Drip Line <br /> 41 ❑ Holding Tank 48 El Single Pass <br /> 22❑ Pressurized In-Ground 30❑Other <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating f O` n C <br /> in <br /> V.Dis ersal/Treatment Area Information'�rsal Soil A plication Percolation Rate Sys t m Elevation teal Grade <br /> Design Flow(gpd) DispeRequirsal DProsed <br /> Area Rate(Ga1s.IDays/Sq.Ft.) (Min./Inch) Elevation <br /> Manufacturer Prefab Site Steel Fiber Plastic <br /> Total Number <br /> VI.Tank Info Capacity in Concrete Constructed Glass <br /> Gallons Gallons of Tanks <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 5)(Q111J PC C X <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> MP/MPRS Number Business Phone Number <br /> Plumber's Name(Print) umber's Signature <br /> 5� az 6 �89 (7�s� Gy <br /> 3 -BJ50 <br /> 6 &1 Code) <br /> Plumber's Address Street,City,State,Zip <br /> C) 3N Sta-k Rogd a7 <br /> VIII. Count /De artment Use OnlyDIssued Issuing Agen ignamre trips)Permit Fee(includes Groundwater ale <br /> Approved ❑ Disapproved Surcharge Fee� 0/ <br /> ❑ owner Given Initial Adverse �f <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County ody)for the system oa paper not leas than 81/2 x 11 taches In size <br /> SBD-6398 (R. 05/01) <br />