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^ ` -'ui W. WashingtonAve., P.O. Box 7162 <br /> �sC��s�n Madison, WI 53707 -7162I Site Address <br /> 0e artment of Commerce .47olljQ,,; ;��(• <br /> Sanitary Permit Application I Sall Permit Number <br /> In accord with Comm 93.21.Wis. Adm.Code. I <br /> personal information you provide n <br /> may be used for Seco purposes Privacy Law,s15.04(1)(m) ' ❑ Check if Revision 7V', 32- <br /> I. Application Information-Please Print All Information <br /> q q Snm Plan I.D. Numocr <br /> Property Owner's Name D ( � <br /> Parcel Number <br /> Nar( Sfah l Old - 4J13- 017-06 I I <br /> Property Owner's Mailingng Address <br /> Property L:caaon <br /> City,SateSE 'A NF 'A:S Q T 90 N.R /3 <br /> Zip Code Phone Number Lot Number <br /> Black Number <br /> I <br /> Subdivision Name CSM Number <br /> Ma ll /YIN. S-s C7 &S-1-738- 7699 <br /> U.Type of Building(check all that apply) <br /> .®-1 or 2 Family DwellingClary <br /> -Number of Bedrooms <br /> ❑ Public/Commercial-Describe use Elvillage <br /> ❑sane Owned !tovmShip Jill k so n <br /> Neatest Road /J <br /> III.Type of Permit: (Check only one box on line A(numbering 8r;dje_ <br /> rI scheme for internal use). Complete lice B if applicable) <br /> A 1 Q New 2 Replacement/w Rep System 3 Replacement of 6 ❑ Additionto For County me <br /> stem Tank ON S stem <br /> B. ❑ Check if Saniary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 'Non-Pressurized In-Ground - 210 Mound 4711 Sand Filter 50 Cl Constructed Wetland <br /> 22❑ Pressurized Lt-Ground 41 Holding Tank 49[3 Single pass 51 Cl Drip Line <br /> 45❑ At-Grade 46 Q Aerobic?reatmeffi Unit 49[]Recirculatiag 30 Other C <br /> V.D' t Area Information: <br /> Design Flow(gpd) Dispersal Area7GalionsofDispersal <br /> Area <br /> Sod Application Percolation Rare System Elevation Final Grade <br /> Rare(Ga1s.lDays/Sq.Ft.) (vlin/Incb) <br /> 3OQ upper 94.a Elevation ?8 I <br /> 6ao S` lounr qa•� �l�p <br /> VI.Tank Info Capacity iner I Prefab Site <br /> Steel Fiber <br /> «trey I Plastic <br /> Gallons ks Concrem Constructed Glass <br /> New Existieg <br /> Tanks Tanks <br /> ;Scpuc <br /> E0"1=Ho14EMTznk <br /> 7S.a 7r0 <br /> 5-00 s 00 = I i <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for iastallation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature Signature MPfMPRS Number <br /> law <br /> Phone Number <br /> q-1S7 <br /> Plumber's Address(Street,city.sore.Zip coda) <br /> 27 7 (a 0 )4w �iS <br /> Coun /De artment Use v <br /> atriary Permit Fee(includes Groundwater Date Issued I Issuing at igna _ ,. o Stamps) <br /> Approved Cl Disapproved S <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse O© I t <br /> Determination U(r 03 <br /> IX. Conditions of ApprovaUReasons for Disapproval <br /> Attach complete plans(to the Cotmp oll for the"em on paper not less than 91/2 x 11 inches in size <br /> SBD-6398 (R. 05101) �` 0, <br /> � ti D <br />