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Safety and Buildings Division coAff <br /> 201 W. Washington Ave.,P.O.Box 7162 t//t/VE <br /> N*Isconsin Madison,WI 53707-7162 Site Address <br /> De artment of Commerce <br /> �taSanitary Permit Number <br /> Sanitary Permit Application =+a , 9b 1 00 <br /> lin accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> ❑ Chec if Revision <br /> may be used for secondary purposes Privacy Law,sl5. 1 m <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> j�t/`-/— �ec, y —ba-.SDC) <br /> Property Owner's <br /> Mailing�Add/ressst / ,.t Property Location �/ -7 <br /> t o e l�Yt- 4-5%J A:S ! T --reN.R �! E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> II.Type of Building(check all that apply) ❑City <br /> 91 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑ Public/Commercial-Describe Use r— /: <br /> i�Township f�-/��� <br /> ❑State Owned Nearest Road 7b <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 ❑ New 2 XReplacement System 3 Replacement of 6 ❑ Addition m <br /> system Tank Only Existing System <br /> B. 11 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 /> 44 [Pion-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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.Ft.) (Min./Inch) Elevation <br /> , 7 X3. 0 96. 0 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> Te!-T!xisting <br /> Tanks sTanks <br /> Septic or Xp 0 0 <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Awe <br /> Plumber's Address(Street,City,State,Zip Code) <br /> e�✓ sr/�72 <br /> VM-County/Department Use Onl <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Age 'gnature(No ps) <br /> Approved 11Disapproved Surcharge Fee) - <br /> ❑ Owner Given Initial Adverse ` �� �✓ �j•/Z 0`� <br /> Determination r pi 7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �t:2iFILA71c>v of Sert Cow/lfltat)s" $r�(:�T 6;LzAS — 4'y LZc>J� <br /> Attach complete plans(to the County only)for the systm on paper not less then 81/2 x 11 Inches in alae <br /> SBD-6398 (R. 05101) <br />