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Safety and Buildings Ulvlston Uounty <br /> 201 W. Washington Ave., P.O. Box 7162 �ac rile <br /> iseonsin Madison,WI 53707-7162 Site Address a-713W <br /> Department of Commerce ePWAoAS /39J E Z4d- <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> C1 Check if Revision <br /> may be used for secondary purposes Privacy Law 05.04(1)(m) <br /> I. Application Information-Please Print All Information Sale Plan I.D.Number 1/50 3 6S <br /> Property Owner's Name Parcel Number <br /> 147,HI.t.EA) a r4ni D/�?-33De� `•off Loa2o <br /> Property Owner's 'Mailing Address Property Location <br /> ^5 ISA nk)'A;S L T39 N,R/(s 4� <br /> City.State Zip Code Phone Number Lot Nu ber Blcck Number <br /> Subdivision Name CSM Numbr <br /> �•G9 o it lry D63y 71S (o3 S- 6659 ✓/8 .256 7 <br /> II.Type of Buil ing(check all that apply) ❑City' _ <br /> X1 or 2 Family Dwelling-Number of Bedrooms 7, ❑Vdlage _ <br /> ❑Public/Commercial-Describe Use QTowpship a2kzn&2z <br /> ❑Stam Owned Nea st Road <br /> ate. 94 /3 rd <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Completelline B if applicabls:) <br /> A. 1New 2 ❑ Replacement System 1 3 ❑ Replacement of 6 ❑ Addition to For County use', <br /> S stem Tank Onl Existin System <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Dam Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 2g Mound 47❑ Sand Filter 50❑ Constructed Welland <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 Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./inch) Elevation <br /> 3oo 300 300 7 ,oworp h 9S. 62— '97.6L <br /> VI.Tank Info Capacity in Total Number Manufacturer Pre(ab Site Si cel Fiber Pl; ;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic 0LHA'a*_ ^v 7$29 _ 754 ,)( <br /> Dosing Chmnbcr .SDO 1606 ., <br /> VII. Responsibility Statement- I,the tinAersigried,aspnie responsibility for installation of the POWTS shown on the attached pkims. <br /> Plumb }RagfPdn, s Sig MP/MPRS Number Business Phone NumberrSrr �1 & EXCAVA <br /> 616228 C01 <br /> I <br /> o7�sr�7y <br /> Plumbers �dsr�aafdl�et,t fy.54e(Atp Cad <br /> II''UU7VV1�t��5--6►►35-7482 <br /> VII . County!De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ent gna re Stasi ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse q(7 49 <br /> Determination `!� �J� (J <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete pram(to the County only)for the system on paper not less than 9112 x I t inches in size <br /> SBD-6398 (R. 05/01) <br />