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Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 6te.rrl-e <br /> ` isconsin Madison, Wl 53707 -7162 Site Address <br /> Department of Commerce 7087 N. Narderi Lk p>'� <br /> Sanitary Permit Application Sanitary Permit Number ' <br /> In accord with Comma 83.21, Wis. Adm. Code,personal information you provide ❑ Check if Revision "7�-s O�� <br /> may be used for seconds purposes Privacy Law, s15.04(11(m) 111 ✓✓✓ __ <br /> I. Application Information-Please Print All Information ^ Sate Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> D q,bo ra Ll #/ er 034 3—S-3:44 <br /> 03600 <br /> Property Owner's Mailing Address Property Location _ U'�•CZr Off. <br /> /b <br /> /IV 60 .p 14:S 341 Tcf( N, R' E <br /> City,Sate 'Lip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> R.Type of Building(check all that apply) ❑Ci <br /> ry <br /> N11 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑ Pubiic!Commercial-Describe Use 19Township Sf^/rsS <br /> ❑ Sate Owned Nearest Road <br /> Al //ayAeh C.k l�rr <br /> III. Type of Permit: (Check only one box online A (numbering scheme for internal use). Complete line B if applicable) <br /> A. fir- For County use <br /> 1 r New 2 Replacement System 3 ❑ Rcpiacement of 6 ❑ Addition to <br /> Sstem Ta:Jc Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal Ilse) <br /> 44 4'Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48 Single Pass 5i ❑ Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other f <br /> V. Dispersal/Treatment Area Information: <br /> Design blow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Ele•,ation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) 9G.3 Elevation <br /> Sop . 7 9T i +a• s <br /> VI.Tank Info Capacity in Toa] Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Ga Ions Gallons of Tanks Concrete Constructed Glass <br /> New Existing —� <br /> Tanks Tanks <br /> Septic or Holding Tank eew - glee <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> c�fAcv �r/s 2 's`° 22 S8 S 1 7 15- g66- 41S? <br /> Plumber's Address(Street,City,Sate,Zip Code) <br /> Z7 7 (00 /4wf 35 EB , _�4ao3 <br /> VIII. County/De artment Use Cl4ily <br /> Approved 11 Disapproved Sanitary Permit Fee(includes Groundwater Date Issued VAignature amps) <br /> Surcharge Fee) y. <br /> ❑ Owner Given Initial Adverse 71j)� 0'L <br /> Determination <br /> IX. Conditions of ApprovaUReasons for Disapproval <br /> jj <br /> AUG.` 2 2 I <br /> Attach complete plans(to the County only)for the.sypRpaper not less than 81/2 x 11 I c e is size <br /> ETT COUNTY <br /> SBD-6398 (R. 05101) ZONING <br />