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wateryandBuildings Division County <br /> iseonsin 201 W, Washington Ave., P.O. Box 7162 t,r t,1e -4 - <br /> Madison, WI 53707 -7162 <br /> Department of Commerce da Stm Address <br /> ' *e�5 Armin �' ZBoiGv <br /> Sanitary Permit Application 1 Sanitary Permit Number O <br /> In accord with Comm 83.21,Wis. Adm, Code, personai information you provide <br /> may be used forseeondaty ses Pnvacv Law. s15.DQ n(m) I '1 Check if Revision�[ '7� <br /> I. Application Information-Please Print ;UI Information N <br /> � /;. [� a7�3(p i Stale ?Ian LD. Number <br /> UJ <br /> Property Owner's Name <br /> / •' / ! Parcell Number <br /> property Owner's Mailing.Address 022 qI-K 03 4f)o <br /> O O j Propem i..ocadon <br /> City, Stam S 7 O NR <br /> . <br /> Zip Cain PhoneNumber T Lot Number <br /> I Z ti/ Block Yumtr. <br /> SuaLvlston Name CS."t Number <br /> rYJ.rv6iv w: 5"y8 e(711) X!s'- N6 <br /> II. Type of wilding(check all that apply) n4"4110 <br /> 1 or_Family Dwelling-Number of Bedrooms <br /> Public.'Commercial-Describe Use !'�V11age <br /> El �[.L <br /> State Owned TOwnshiD �CO,42L <br /> j Nearest Road <br /> III. Type of Permit: (Check only one box o <br /> A. n line A (numbering scheme for internal use). Complete line B if ppiiicab e) WA <br /> 1 Isew 12 Replacement System 3 i Replacement of 6 Addition:o For Corm[y use <br /> Svsrem <br /> Tank Only i Existing Svstem <br /> B j J Check if Sanitary Permit Previously Issued Permit Number <br /> ' j � � Date Issued <br /> i <br /> N. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Von-Pressurized In-Ground 21❑ Mound <br /> 47 L7 Sand Filter 50 r Constructed Wedar•d <br /> 2❑ Pressurized In-Ground 41 L7 Holding Tank 48�] Single Pass <br /> j g 51 E Drip Line <br /> 145 At-Grade 46 F"Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dis ersal Area <br /> ��O I Required p Sou Application Percola[ion Rate System E1evaCCa <br /> �/ Prop/used Raie(Ga!s.lDays/Sq.Ft.) rMin./Inch) j Fisc`""` <br /> �-0 3 O /YP . _7 E!ays^.cn�.. <br /> VI. Tattle Info Capacity in Total i Number <br /> Manufacturer PreSim <br /> fab Stee! F•rrr c�, <br /> GallonsGallons of Tanks suc <br /> Nrr Eusrsg Sic- <br /> Concrete Construcmd v:zrs <br /> Tarxs I Tanks <br /> j Septic or Holding TankI <br /> 1/600 /Qop N <br /> i Dosing Ctu[^ccr <br /> ofW(Gil x <br /> VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the P01,7S shown on the attached plans. <br /> Plumber';Name(Pring Plumber'i Si ramre �t _ <br /> -�j I P/MPRs Number 3usiness ?hone Nude; <br /> L'�{{f}QZD 7W PK/wS z2S — <br /> P',imcer s tuuress(Street. Cry Stat_ Z o Codi <br /> 27 7 (oo /4w7 (,./EE�-5M jph , �4SJ3 <br /> j11TC,,,un1v1,D,e artmentLse lvroad Disaparovcd adttry i' rn;; Fn r...UL <br /> m v..^;urd'uater Late lti,u.. �. <br /> Sur har3 d tasu.ng <br /> 0wr.er Given Initial Adverse <br /> DeAppranen ��— <br /> i LY. Conditions of ApprovaUReasons for Disapproval <br /> I <br /> �— Attach complete plain Rn the Couo;v anla(ar the syrema — <br /> nn p�per pat Icss than 31,'2 <br /> SBD-6393 (R. 05101) <br />