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Safety and Buildings Division County _ / L <br /> 201 W. Washington Ave.,P.O. Box 7162 u(Mel- <br /> ` Madison, WI 53707 -7162 Site Address <br /> �sconsin <br /> De artment of Commerce 72 g3 ;' e/951e <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21.Wis.Adm. Code,personal information you provide ❑ Check if Revision L/L to <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> jer4 ealnereoma dZo Z5 02 zav <br /> Property Owner's Mailing Address Property Location / <br /> N 1/4 'A:S T`O N, RA6 E <br /> City, State Zip Code Phone Number Lot Nuryber Block,umber <br /> C <br /> !,1" k30-/y5o 6 <br /> Subdivision Name CSM Number <br /> 51 <br /> & 08 Z H(,Iq) y,e-2_Z:,6j/ <br /> if.Type of Building(check all that apply) ❑City <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms y ❑G�oVillage <br /> ❑ Public/Commercial-Describe Use L1Township Oq,�J,?Al <br /> ❑ State Owned Nearest Road <br /> A <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 ❑ New 2 �Replacement System 3 ❑ Replacement of 6 El to <br /> S tem Tank Only Existing System <br /> B. Check if Sanitary Permit Previously Issued Perini[Number Date ssued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use <br /> 44 Non-Pressurized In-Ground 20 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 <br /> ina <br /> l Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) 97d Elevation <br /> 000 7 � <br /> 9S� 43,Z 45 -z. <br /> VI.Tank Info Capacity inTotal 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 1200 .,Z� k444 X <br /> Dosing Chamber P� 75?� <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> c }ozv ,r/S 22S$S 715- S66- 4157 <br /> Plumber's Address(Street,City,Stare,Zip Code) <br /> 27-7 &0 f+w 35 fB �4$ 3 <br /> VIII. County/Department Use Ofil <br /> Sanitary Permit Fee(includes Groundwater DDate� ® Issuing Agent Sign N tamps) <br /> pproved ❑ Disapproved Surchar Fee) <br /> [IOwner Given Initial Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> OCT 112002 <br /> Attach complete plans(to the County only)forftibIE! a erCALGAV11"gill x 11 inches in size <br /> ZONING <br /> SBD-6398 (R. 05/01) <br />