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Safety and Buildings utvision county <br /> Washington Ave.,P.O.Box 7162 ZwnCYt' <br /> 201 W. <br /> �Wiscons/n Madison, WI 53707-7162 Site Address <br /> Department of Commerce Lf serf LAKE ill eSS <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide r„n,l\r A> <br /> ❑ Check if Revision /s1�ji 4 Jam_ <br /> ma be used for seen of PrivacyLaw,s15. 1Xm State Plan I.D.Number 1 <br /> I. Application Information-Please Print All Information � � ---1 <br /> Property Owner's Name - Parcel Number <br /> eML4 oza/-31/3 -0S-000 <br /> Property Owner's Mailing Address11 Property Location <br /> o7e/dZ a UGQ�S; /7V✓�. &-e67— 6LLI % A:S / T-3`9 N,R/¢KJ& <br /> City,Sure Zip Code - Phone Number Lg J Black Number <br /> 0 �� o � 3 <br /> Subdivision Name CSM Numbe <br /> ,srPA� /y7,7 6/z- as.K Jt <br /> II.Type of Building(check all that apply) ❑City _ <br /> 0 t or 2 Family Dwelling-Number of Bedrooms Z ❑village :JJ <br /> 11PubliUCommercial-Describe Use Township /-•e./(, — <br /> ❑Suit Owned Nearest Road �i�5 - /1 _ SS <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal use). Complete line B if applicable) J� <br /> BTD <br /> New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> tem Tank ON Existin S stem <br /> Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 X' Non- re sari ed In•�s rgund 20 mound 47 11 Sand Filter 50 C1 Constructed Wetland <br /> .GZ 3,xfvr <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51❑Drip Line <br /> 45❑ At-Gmdc 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. DispersaVTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 300 • 7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber PL•.;tie <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existint <br /> Tanks Tanks <br /> Septic or usmirm-"r r <br /> 00 00 bC <br /> Dosing Chamber <br /> VII. Responsibility State erlt- dersigned,Monne responsibility for installation of the POWTS shown on the attached plow. <br /> r' is Sig re MPIMPRS Number Business Phon:Number <br /> �Y2p8 <br /> COU <br /> LINER eaa 8 s <br /> Plu`7 N <br /> S't WlC54W1Zip Code) U 010VVII • Ce artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dace Issued Issuing All Si ture(N tan ps) <br /> Surcharge Fee) <br /> ❑ Owner Given initial Adverse !2t� IXAY, <br /> nCV./De[etmhDetermination0tion VV <br /> IX. Conditions of ApprovaUReasotrs for Disapproval <br /> Attach complete plane(to the County only)for the system on paper not Im than 3112.X It inches in elf <br /> SBD-6398 (R. 05/01) <br />