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leu N� Safely and Buildings uivuwn uounty�, <br /> �. VJ201 W. Washington Ave., P.O. Box 7162 �^ e <br /> `Wisconsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce a <br /> Sanitary Permit Application Salutary Permit Number <br /> In accord with Comm 83.21.Wis.Adm. Code,personal information you provide )CJ <br /> ma be used for second purposes PrivacyLaw,sl .04(l)(m C1 Check if Revision <br /> I. Application InfotTtlaHon-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> 0 ao <br /> Properly Owner's Mailing Address ---- <br /> l Property Location G / <br /> Sf Li� Sf:S .?l T 0 N.R <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> N /y Subdivision Name CS <br /> .M Numbe <br /> It.Type of Building(check all that apply) _ <br /> OCily <br /> 0or 2 Family Dwelling-Number of Bedrooms — <br /> ❑Public/Com ❑Village <br /> Public/Commercial-Describe Use "'— <br /> Ofownship <br /> ❑State Owned NearestRo <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal tile). Complete line B if applicalih!) <br /> A. For County use <br /> 1 IT New 2�Rcplacement System 3 ❑ Replacement ofLE <br /> ❑ Addition to <br /> S stem Tank Ord stin S stem <br /> B- ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that a pply)(numbering scheme is for internal use) <br /> 44;K Non-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 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.) (,'vfin.fInch) Elevation <br /> moo �/07.7 y.sv / `7 qy, s 9z, 5r <br /> VI.Tank Info Capacityin Total Number Manufacturer Prefab Site Si eel Fiber ph,;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> qNewExistin` <br /> Tanks <br /> Scptie or Holding Tank <br /> Dosing Chamber O 7! <br /> VII, Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's N e(Print) Plumber's Signature MPlMPRS Number Business Phons Number <br /> Plumber's Address(Street,City,State,Zip Code) tl <br /> nV11ount /De artment Use Onloved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing cat ignature tan ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse JU / <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> M*y 6E W15G01JSnJ F`Wl) LC'Lj61$LC <br /> Attach complete plans(to she Counly only)for the system on paper not less than 5112 s I1 inches in size <br /> SBD-6398 (R. 05/01) <br />