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Safety and Buildings Division county <br /> in <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> tisconsMadison,WI 53707 -7162 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sani��23 73® <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> may be used for secondary purposes Privac Law 15. 1 m n , <br /> I. Application Information-Please Print All Information a State Plan I.D. Number w <br /> Property Owner's Name Parcel Number <br /> Property Owner's Mailing Address Property Location T40 <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> ' �� A t , i 55A.�� �('L_ gGi_s ��l Subdivision Name CSM Number <br /> Sr / 1 N 'T L- i>, ow AIBP TO VV <br /> II.Type of Building(check all that apply) 2 (]city <br /> �1 or 2 Family Dwelling-Number of Bedrooms 3 []village <br /> ❑Public/Commercial-Describe Use �r['ownship <br /> ❑State Owned Nearest ad <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete tine B if applicable) <br /> f <br /> j� For County use <br /> "'R New 2 CE] Replace�m System 3 ❑ Replacemem of 6 ❑ Addition to <br /> S stem Tank OnlyExis' S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dace Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44, -Pressurized In-Ground 20 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 Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.F[.) (Min./Inch) /J2 V Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New I Existing <br /> Ta <br /> �n^ks Tanks <br /> Septic or Holding Tank Tanks �. ,OD� CD <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 /> �f}RQLv ir/S <br /> ;7- <br /> Number's <br /> lumber's Address(Street,City,State,Zip Code) <br /> 2.7-7 !o o 14w 315 iFB �4g 3 <br /> VIII. Count /De artment Use 1 <br /> prove <br /> d ❑ Disapproved Sanitary Permit Fee(includes Groundwater :DateIssued Issuing Agent Si nate (N s) <br /> vv Surcharge Fee) 11 <br /> ❑ Owner Given Initial Adverse �`�DO`(}� Ca n <br /> Determination f t� l�I <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches is size <br /> SBD-6398 (R. 05/01) <br />