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Safety and Buildings Dtvtslon t.ounry <br /> 201 W. Washington Ave- P.O. Bo<7152 j�u.rnE� I <br /> 11 iseonsin Madison, W 1 53707 - 7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> in accord with Conroe&3.21,Wis.Adm.Code,personal information you provide �78'(%� d <br /> _ __ <br /> may be used for second purposes PrivacyLaw, 15.04(1)(m) ❑ Check if Revision <br /> 1. Application Information-Please Print All Information Sure Plan LD. Number <br /> _ 3& II & <br /> Property Owner's Name Parcel Number <br /> Jve C e Dd.Q ^�/3?S ^Ol�OD <br /> Property Owner's Mailing Address Property location G C)V'£,. c6T5 <br /> 6SOS ooto/S 6/6 iP104' 'A u:S3s T 40N, R /(n <br /> City,State Zip Code Phone Number tat Number + Blcck Number <br /> Subdivision Name CSM Number <br /> y93 � s - gr7we 511- Z CsmVr3 L3 <br /> II.Type of Building(check all that apply) ❑City _ <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village _ <br /> ❑Public/Commercial-Describe Use ®Township Cf/Caagec/q1 <br /> ❑State Owned Nearest Road <br /> 0&11i15 « ted. <br /> III.Type of Permit: (Check only one box online A (numbering scheme for internal use). Complete line B if applicably.) <br /> A. r� For Courtly nue <br /> 1 El Ne 2/F' Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem ` Tank ON Exisdn 5 stem <br /> B. ❑ 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 ❑ Non-Pressurized In-Ground 21M Mound 47❑ Sand Filer 50❑ Constructed Wedand <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑ Drip Line <br /> 45❑ At Grade 46❑Aerobic Trtatment Unit 49❑Recirculating 30❑Other _ <br /> V. DispersaUTreatment Area Information: _ <br /> Design Flow (gpd) Dispersal Area Dispersal Arra Soil Application Percola;ion Rate Systcm Elevation Final Grade <br /> Required Proposed Ram(Gals./Days/Sq.FtJ (Min./Inch) Elevation <br /> 4sD vso Soy 9 97 3 <br /> VI.Tarek Info Capacity in Tout Number Manufacturer Prefab Site Seel Fiber PI; aic <br /> Gallons Gallons of Tanks Concrete Consuuaed Glass <br /> New Existing <br /> Tanks Tartkt <br /> Septic or Holding Ta.Nt /060 X000 <br /> During Chamber /.00 60l) <br /> V . Responsibility Statement- I, the u idersi(ued, assume responsibility for installation of the POWTS shown on the attached pl,Its. <br /> Plumber's Name(Print) Plumber's Signature / MP/MPRS Number Business Phon a Number <br /> Rie-a- f{n r n s <br /> Plumber's Address(Str/l.-eet.City,Sure,Zip Code) <br /> _� 7760 //—/ -3s—aX0,12 �� y✓�3 8x73 <br /> VIII. Count /De artment Use Ong <br /> CItary Permit Fee(includes Groundwamr Date Issued Issuing a ignaw o Su. ps) <br /> Approved 13 Disapproved Sani <br /> Surcharge Fee) _ <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> [X. Conditions of Approval/Reasons for Disapproval <br /> Attach compiere plans(tu the County ooty)far the system on paper not len than g1R z 11 mehm io sur <br /> SBD-6398 (R. 05/01) <br />