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Safety and Buildings Division County <br /> As . Washington Ave., P.O. Box 7162 nl pZY <br /> A 201 W <br /> sconsin Madison, WI 53707 -7162 Site Address I <br /> Department of Commerce agJrg �(yl��Or jit <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code, personal information you provide ��n 4-4 <br /> / ,f <br /> m be used for second purposes PrivacyLaw 15. 1 m El Check if Revision b `f-`/' <br /> I. Application Information-Please Print All Information J,� `l State Plan I.D. Number <br /> Property Owner's Name --�-f� Z, Parcel Number n.(1 <br /> C u 0 3 6 30o V <br /> Property Owner's MailingAddress <br /> „s � Property Location <br /> 0 �✓ W,T/d r0 �/r///i`I 'A 'R:S l 3 T y0 N,R / <br /> City, State Zip Code Phone Number Lot Number Block Number <br /> � 3 <br /> /I Subd vision Name CSM Number <br /> U.Type of Building(check all that apply) ❑City <br /> Aor 2 Family Dwelling-Number of Bedrooms 3 ❑Village _ <br /> ElPublic/Commercial-Describe Use ` <br /> ❑State Owned wrest Roaownshipd el/t�i O/ J <br /> Nearest Road <br /> aY5-97 /',41,n 6or <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 ❑ New 2*eplacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I I T77Number <br /> On[ ExistingSystem <br /> B. 11 Check if Sanitary Peanut Previously Issued Date Issued <br /> IV.Type of Permit: (Check all that apply)(numberitlg scheme is for internal use) <br /> 44�4?,Ion-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 3o❑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 Raw(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> y5 6 y3 �sd <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 ,r.` _ 14w_ 0 <br /> Dosing Chamber G(J <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signamre MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,QOX /y _S5/-.e_- 1-✓:;t7 <br /> VIII. County/Department Use Only <br /> Approved 11 Disapproved Sanitary Permit Fee(includes Groundwater Dare Issued Is Agent Si mre(No Stamps) <br /> Surcharge Fee) / <br /> ❑ Owner Given Initial Adverse 2✓0 e C6 OS <br /> Determination ri <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete Alam(to the County only)for the system on paper not less than 81/2 x 11 Inch”In size <br /> SBD-6398 (R. 05/01) <br />