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Safety and Butldtngs Urvnston county <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> Nvisconsin Madison,WI 53707-7162 Site <br /> ASress <br /> re <br /> ND f Co. 11 r <br /> De artment of Commerce sanitary PerrJmit Number t' XhJ <br /> Sanitary Permit Application �J <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> ma be used for Seco ses Privac Law,$15. I)(m State plan I.D.Number <br /> I. Application Information-Please Print All Information n�7 <br /> Parcel Number <br /> Property Owner's Name <br /> Kew ��c% ,� 0 3� s-3c- 0 3 ydd <br /> Property Location �- <br /> Proper/ntyy Owner's Address _ <br /> /✓O /3 ex --25/ S C Siber u:S 3� <br /> City,State <br /> Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM NumIx <br /> / <br /> 11.Type of Build g(check all that apply) LJCtty — <br /> %1 or 2 Family Dwelling-Number of Bedrooms OVillage�, — <br /> ❑Public/Commercial-Describe Use ' owmhip Swiss <br /> Nearest Road <br /> ❑State OwnedL . so <br /> Ill.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete e B if applicable) <br /> use <br /> A 1 ❑ New 2,1 Replacement System 3 Replacement of 6 ❑ Addition to <br /> For County <br /> S stem Taok Onl Existin S stem <br /> Fermi[Number <br /> B. D Check if Sanitary Permit Previously Issued <br /> Date Issued <br /> IV.T pe of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 on-Pressurized In-Ground 2111 Mound <br /> 47❑ Sand Filter 50❑ Constructed Wetland <br /> 41 ❑ Holding Tank 48 13 Single Pass 51 ElDrip Line <br /> 22 13 Pressurized In-Ground g <br /> 45(] At-Grade 46 0 Aerobic Treatment Unit 49❑ 30❑OtherRecirculating <br /> V.Dis ersaUTreatment Area Information: <br /> Design Mow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Elevationde <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./inch) <br /> y.s'o 6 <br /> Capacity in Total Number Manufacturer Prefab Site Sleet Fiber ph ;tic <br /> VI.Tank Info P ty Concrete Constructed Glass <br /> Gallons Gallons of Tanks <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank ..r- �D0 A' T <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached pl:�_. <br /> Plume(P,ju t) <br /> Plumber s Signatur MP/MPRS Ntunher Business Phone Number <br /> Ila ale, <br /> Plumber's Address(Street,City,State,Zip Code) OF <br /> VIII. Count /De aliment Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent cure(No Sill ps) <br /> Approved ❑ Disapproved Surcharge Fee) t <br /> ❑ Owner Given Initial Adverse <br /> Determination +r <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than al/2 x 11 inches in sive <br /> SBD-6398 (R. 05/01) <br />