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Safety and Buildings Division County <br /> ly- j ?" 201 W.Washington Ave.,P.O.Box 7162 CG/f�.tl <br /> sponstn Madison,WI 53707-7162 Site Address <br /> eoartm8nt of Commer0e &to1C-:M3 <br /> Sanitary Permit Application VSanitary Permit Number 3� y <br /> in accord wide Comm 93.21,Wis.Adm.Code,personal information you provide <br /> _ <br /> may be used for seen purposes PrivacyLaw,s 15. 1 m ❑ Check if Revision <br /> A. Application Information-Please Print All Information State Plan I.D.Number <br /> Prope <br /> Owner's Name Parcel Number XO <br /> !/L: O LLL 57-7`0 2, -2 Pe 0 <br /> Property Owner's Mailing Address n Property Lorxtion <br /> �(/W M Elf:S T N,R <br /> City,State • Zip Code Phone Number Lot Number_ Bl�Nuumber <br /> &rehs / Subdivision Name CSM Number <br /> II.Type of Building(check all that apply) ❑city <br /> N /J <br /> ,�T 1 or 2 Family Dwelling Number of Bedrooms ❑Village / <br /> 0 PubdriComrnercial—Descrux Use <br /> ❑State Owned Nearest <br /> al <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B applicable) <br /> A. For County use <br /> 1Ncw 2 ❑ Replacement System 3 ❑ Replacement of �Exlilsurustyylos;tetrm <br /> I <br /> $ stem Tank Only <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dam Issued <br /> IV.Type of Permit: (Check all that apply)(nttmbering scheme is for internal use) <br /> I <br /> 44 ❑ Non-Pressurized In-Ground 2XMound 47❑ Sand Filter 50❑ Constructed Wedand <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 Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.FI) (Min./Inch) Elevation <br /> 4!!�00 6M moo 951 F3 97, / 3 <br /> VI.Tank Info CO2sin . Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Teaks Concrete Commented Glass <br /> New Eaisting <br /> Tanks Tadd <br /> r Holding Tank - <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Mumber's Name(Print) Plumber's Signature MP/MPRS NumberBusiness Phone Number <br /> lumbo 's (street:City,sem.zip code) <br /> Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary <br /> Permit a Fee) <br /> (dudes Groundwater Dam Issued Issuing gem Signature(No Stamps) <br /> Sumbarg <br /> ❑ Owner Given Initial Adverse l t D-SQ o 0 O �o�� AUL <br /> Determination <br /> 11 Ll <br /> IX. Conditions of Approval/Reasons for Disapproval j <br /> u j_ _ 1 <br /> JUL 16 2001 J <br /> i <br /> Attach complete plans(to the County only)for the system on paper not less thea SM s IIB=W I I WUNTY <br /> ONNG <br /> SBD-6398 (R. 05/01) <br />