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Safety and Buildings Division County <br /> � 20: W. Washington Ave., P.O. Box 7162 <br /> I seonsin Madison, WI 53707 -7162 Site Address <br /> Department of Commerce GS(V g /1ay�esr <br /> Sanitary Permit Application Sanitary Permit Numbe` --In accord with Comm 83.21,Wis. Adm. Code, personal information you provide <br /> may be used for secondary 2u22ses Privacy Law.s1 .04(1)(m) ❑ Check if Revision G O '7 <br /> (_ � �v <br /> I. Application Information-Please Print All Information � State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> Si4eile LTf Orn 5a' 302, —01-30b <br /> Pmpery Owner's Mailing Address Property Location V't-COT S <br /> 3' 96 S /l PDQ �n P LS/✓� '4 S of T Ufa N. R 16 E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> U/Ar'Ye 13eet.t Gk M A/ 3Si/O 6 5`/-6x3-970x2 S <br /> H.Type of Building(check all that apply) ❑City <br /> Gt1l or'-Family Dwelling -Number of Bedrooms_ 0-Village _ <br /> ❑ Public.'Commercial-Describe Use tyitownship a)17 k/a.,® <br /> ❑State Owned Nearest Road <br /> hl�y�PrH G/c /c'oF <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. <br /> 1 ❑ New 21<Replacement System 3 ❑ Replacement of6 ❑ Addition to For County useS stem I I Tarik Onlv --tExisring 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 use) <br /> 44 AK Non-Pressurized In-Ground 2111 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. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Ele,ation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (NI im.iInch) Elevation <br /> `7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New existing <br /> Tanks Tanks <br /> Septic or Holding Tank S'OQ _ <br /> Dosing Chamber <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 /> �tfflazv „✓s �_ 22.53 S 1 715- 566- 4 -57 <br /> Plumber's Address(Street,City,State, Zip Code) <br /> 2.77 &v 144 35 Ugssrm , X48 3 <br /> VIII. County/De artment Use Ofily <br /> i Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent n re(No psi <br /> Surcharge Fee) -� <br /> ❑ Owner Given Initial Adverse uJ <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> T� SEP - 2004 <br /> 13URNETT COUN <br /> Attach complete pians(to the County only)for the system on paper not less than SV2 x 11 inches 2UNING <br /> SBD-6398 (R. 05101) <br />