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Safety and Buildings Division Courtly p <br /> 201 W. Washington Ave., P.OBox 7162 <br /> Madison, WI 5370 -7152 S—i;—eAddress`��SCOn in ,— Qu e Loy) <br /> Department of Commerce Sanitary Permit fr <br /> � e <br /> Sanitary Permit Application 458� <br /> In accord with Comm 83.21,Wis. Adm. Code. personal information you provide El Check if Revision <br /> may be used for secunda 2u!125e5 Privac Law,s15.04(1)(m) State plan I.D. Number <br /> I. Application Information-Please Print All Information /^ <br /> VJ Parcel Number <br /> Property Owner's Name <br /> ,f� t.or� soti�so�l dab-�flbg - foo <br /> -� <br /> Property Location �� ,(��' <br /> Property Owner's Mailing Address <br /> S Vp T YD N,R /4 E <br /> F. 9/lf$r ZON Lot Number Block Number <br /> City.State Zip Code Phone Number <br /> Subdivision Name CSM Number <br /> �aN 6JA wL S-elT30 7;F,-s-_ ,,S-I- 767.3 <br /> II.Type of Building(check all that apply) ❑Ctry <br /> 91 or 2 Family Dwelling-Number of Bedrooms �T L1Village --- <br /> ❑ Public'Commercial -Describe Use ffTownship SGo'`IF'— _— <br /> Nearest Road <br /> ❑State Owned ZooLk Rol <br /> III.Type of Permit: (Check only one box online A (numbering scheme for internal use). Complete line B if applicable) <br /> For County use <br /> A. <br /> 1 ❑ New 24Replacement System 3 ❑ R:piaczment of 6 Addition to — <br /> S stem Tank Only Existing Svstem <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 22 Pressurized In-Ground Non-Pressurized In-Ground 210 Mound <br /> 47 El Sand Filter 50 El Constructed Wetland <br /> ., 41 C Holding Tank 48 0 Single Pass 51 11 Drip Linz <br /> 2�G <br /> 45❑ At-Grade <br /> 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application P f ollncoh)Rate System Elevation Elevation <br /> ornde <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (. pp <br /> ~ lower �II.S� 9`t. <br /> fes-/v SS7 516 4 <br /> Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Ca <br /> VI.Tank Info p ty Gallons of Tattles Concrete Constructed Glass <br /> Gallons <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /d'.S-& - SK�y W <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the tmdersigrred,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plttmber's Signature MP/MPRS Number Business Phone Number J <br /> Plumber's Name(PrinU n�� /G A, 1S- (�66- 1 t�� <br /> Gf{fl4ZJ� 1r�S C �- "^ zj <br /> lumber's Address(Street,City,State,ZipvCode) <br /> 2-7-7 (00 141w 35 UfBSTM W1 , X48 3 <br /> V 1. Count /De artment Use Oftly <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Age tgnatur o Stamps) - <br /> Approved ❑ Disapproved Surcharge Fee) r <br /> ❑ Owner Given Initial Adverse Q �V/jo �� 7�t� 6'f' - <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval n <br /> JUL 2 0 pppq <br /> BURNETT <br /> Attach complete plans to the County only)for the system on paper not les than 8112 x 11 Inches in sizeONING <br /> SBD-6398 (R. 05101) Y7 <br />