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VW= -NatetyadBuildingsDivision County <br /> Wisconsin 201 W.Washington Ave..P.O. Box 7162 eu Y n t f <br /> Madison.WI 53707-7162 Site Address <br /> De artment of Commerce Z Q� <br /> Sanitary Permit Application Smutary Permit Number i <br /> In accord with Comm 83.21,Wis.Adm,Code,personal infomration you provide <br /> ma be used for seep ! <br /> es Priv Law,s15. 11 ml ❑ Check if Revision <br /> I. Application Information-Please Print All Information �f <br /> Stare Plan LD. Number <br /> Property Owner's Name <br /> Parcel N=her <br /> Larr <br /> OU SA 3o d, <br /> Prpe <br /> orty Ownei s ing Address d Q- <br /> ���3 Property Location <br /> City,State Zip Code Phone Number Sr % i, u:S O T 41 N.R 1S <br /> Lot Number Block Number <br /> Sk rte.' Wt. Syg80diision,Name CSM,Number <br /> -rrs-o\1'1- 79 d I Subvr� <br /> ' <br /> H.Type of Building(check all that aPP1Y) <br /> V. <br /> 19 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑City <br /> ❑Public/Commercial-Describe Use <br /> []village <br /> ❑State Owned ATownship SW <br /> Nearest Road t' n <br /> III.Type of Permit (Check only one box on line A (numberinA. g scheme for interna!use). C plete line B if applicable) <br /> ) <br /> 1 X New 2 ❑ ReplacementSystem 3 ❑ Replacement of 6 ❑ Addition, .Y <br /> For Co use <br /> S stem Tank Onl <br /> Eris' S stem ! <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Dare issued <br /> IV,Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 LR Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter <br /> 50❑ Constructed Wetland <br /> 22❑ Pressurized In 41 ❑ Holding Tattle <br /> 48❑ Single Pass 510Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30 C1 Other <br /> V. Dig ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil A licadan <br /> PP_ Percolation Rate System Elevation Final Grade <br /> ��� Required Proposed Rare(Gals./DayslSq.Ft.) (Min./Inch) <br /> 6143 Elevation <br /> 6 4 8 . 7 94 d: ge <br /> VI.Tattle Info i Capacity in I Total Number Manufacturer <br /> Gallons Gallons I of Tanks Prefab Site <br /> I Steel I Fiber Plastic <br /> Concrete Constructed Glass <br /> New Existing � . <br /> Tanks Tanks , � I '. <br /> Septic or Holding Tank I/eoO j <br /> iDosing Chamber <br /> VII Responsibility Statement I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans, <br /> Plumber's Name(Print) I ?!umbels Signature - <br /> -�jj MPlMPRS Number t Business Pbone Number <br /> 1�t«fRc�D p ei�✓s �s� I z <br /> ZSS S Q �J <br /> lumbers Address(Street,City,state,p Code) ' I�— ✓��— I r�� <br /> 277 too f-Fwy �S (,.I�BSTrz Inl! X48`13 <br /> VH uuntv/ue artment Use(lhly <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwawr Date Issued Issuin o- <br /> n Surcharge Fee) Issuing. Signatu% i lio .,amts; <br /> Owner Given Ini ial Adverse LCID i �-4 r <br /> Detetmiration �V _l <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> ) <br /> evq <br /> Attach complete plain ito the Couoty poly)for the syrtem on paper not fess than ffi/'-x 11 inches io size 2 �_S�0 <br /> �CN/ <br /> �SBD-6398 (R. 05101) N ' <br /> < <br />