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ff�mCcp"SI� Madison, WI 53707-7162^ 1 <br /> Department of Commerce I I Site Addtrss <br /> awrry�� <br /> Sanitary Permit Application <br /> Sanitary Perrnrt Number <br /> In accord with Comm 83.22 1.Wis.Adm. Code,personal information you provide <br /> ma be used for Seco ses Privacy Law 15. i)ml �� Check if Revis on <br /> I. Application Information-Please Print All Information /t <br /> Sore PI ' <br /> Property Owner's�jName /� W=ig"O{ /L7ot <br /> !J e-4 V ✓a m Parcel Number <br /> i <br /> Property Owner's Marling Address I 0019- '-ill 7 _ Oc. 3a o <br /> Rel I <br /> (fO. /�/7 PtnPerq•Lor3aon <br /> Ciry,Sore zip CodeSE'k SLi/u:S t!7 T <br /> Phone Number N.R Lf <br /> Lot Ntyntur Hlock�ImaL•er <br /> W-6.5 !�� l t/l S7 / Subdivision Name csM Number <br /> II.Type of Building(check all that apply) 7 3 7/s'. G3S- 77d 7 U 1'7 <br /> IR i or 2 Family Dwelling-Number of Bedrooms Clary <br /> ❑Public/Conart ercial-Describe Use ❑Village <br /> ❑Sam Owned ownsltiP SG D 7f'7c <br /> I Nearest Road <br /> III.Type of Permit: (Check only one box on line A(n Ou s/ta Q.- <br /> A. umbering scheme for interna!use), Compiete line B if applicable) <br /> 1,M New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ <br /> stem Tank Od Addition to For County tree <br /> S stem <br /> B ❑ Check if Sanitary Permit Previously Issued Permit Number <br /> Date Issued <br /> IV.Type of Permit: (Check all that apply)(nrmslsering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Grated 219 Mated 11 Said Filter <br /> 22❑ Presnuized Iti-Ground 41❑ Holding rank 4 477❑ Single p� 50❑ Constructed Wetland <br /> 45 C1At-Grade � 51 C1 Drip Line <br /> V.D' tment Area <br /> 46 Holding <br /> Treamtea[Um[ 49❑ 30❑Other <br /> Information <br /> Design Flow(gpd) Dispersal Area Dispersal Area Sor7 <br /> Requited Proposed App�tio' Percolation Rate System Elevation <br /> RaFinal Grade i <br /> 300 3 3 3 Elevation <br /> VI.Tank Info Capacity in Total Number <br /> Gym Gallons of Tanks Mamrfacmrer site I Steel Fiber Plastic <br /> New F I Concrete Coosttucted Glass <br /> Talcs Tanks I <br /> Sepac:or Holding TankDosin7�•-/.j - 7sD <br /> g(7tamher soo �,s`oo <br /> VII•Responsibility Statement- I,the undersigned,assume r"POrmbility for installation of the PG`VTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sigmture <br /> MP/ IFRS Number <br /> [BruslDmPhoneNumber <br /> ZS$S ( 966- MS7 <br /> lumber's Address(Street,City,Sate,Zip Code) <br /> 27 7 (o o 1141,W 3S EB <br /> Coon /D!Dcm <br /> rtment Use 3Q-g 3 <br /> pproved Disapproved Surd a Fee t Fee(incudes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Owttes Given(nidal Adverse V <br /> rmiaatioa �XJ LTJ "�7 �'n� , •_ <br /> 1X. Conditions of Approval/Reasons for Disapproval <br /> I <br /> I <br /> 1 <br /> I <br /> Attach wmplete plans(to the County only)for the system on Paper not It=than 81/2 z Il Inches in sae <br /> SBD-6398 (R. 05101) <br />