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Safety and Buildings Division County <br /> ` 20: W. Washington Ave., P.O. Box 7162 v, -e rr <br /> isevnsin Madison, W'1 53707 -7162 Site Address <br /> Department of Commerce a Rd, rT <br /> Sanitary Permit Application Samtary Permit Number --- <br /> In accord with Comm 83.21, Wis. Adm. Code, personal information you provide <br /> may be used for secondary DuMoses PrivacyLaw, s[5.04(1)im) ❑ Check if Revision <br /> I. Application Information-Please Print All Information <br /> /J / State Plan LD. Numbe; <br /> Property Owner's Name (- b 10137/4 ` <br /> T Parcel Number <br /> Gar - eN 1. 00l. 6 6 <br /> Property Owner's Mailing Address <br /> Property Location <br /> 7/,16 W, AIc/er Sri. 5 � tti 'A <br /> City,State Zi Code 'A.S 6 T 4U N, R I tl <br /> P Phone Number Lot Number Block Number <br /> W uk Subdivision-Name CSM Number <br /> a ee W,r S3�!y y/y�y7S— /9SS` <br /> II. Type of Building(check all that apply) <br /> ❑City, <br /> ❑ 1 or 2 Family Dwelling -Numbe:of Bedrooms <br /> U PublidCortunercial-Describe Use ❑Village <br /> ❑State Owned Township -SCO /7 <br /> Nearest Road <br /> 1R. T y ( �o. /2oQ <br /> Type of Permit: (Check onl one box on line A numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 �New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank Onl Existing S stem <br /> B• ❑ Check[f Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal ase) <br /> 44 ❑ Non-Pressurized In-Ground 2X Mound 47❑ Sand Filter <br /> 50 11 Constructed W'edand <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑ Drip Line <br /> 45❑ At-Grade 46 C Aerobic Treatment Una 49❑Recirculating 30 L1 Other <br /> In <br /> V• Dispersal/Treatment Area formation: <br /> Design blow(gpd) Dispersal Area Dispersal Area Soil Application PP Percolation Rale Sysmm Elevation Final Grade <br /> Required Proposed Rate(,Gals./Days/Sq.Ft.) (Min./Inch) <br /> OO Elevation <br /> 360 3 C7 g8 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Tanks Plas[I <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> Septic or Holding Tank 7.5O <br /> Dosing Chamber soo S�Q <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 <br /> 46-7usiness Phone Number <br /> �4Akq_P �n/s Ci'- ! ;7-2-5 1 7(�= g66- g <br /> lumber's Address(Street,City,State, Zip Code) <br /> 277 (oo 14w �S <br /> VUL Count /Department Use 1 <br /> Ip'Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Age ignature(. amps) <br /> Surcharge Fee) <br /> FD Owner Given Initial Adverse AN � t <br /> Determination1�/ �r v/2 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Anach complete plain(to the County only)for the system on paper not less than 31,x 11 loch"in size <br /> SBD-6398 (R. 05/01) <br />