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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 Y3& I7 <br /> `visconsin Madison,WI 53707 -7162 Site Address <br /> De artment of Commerce <br /> Sari P rmit Number <br /> Sanitary Permit Application ��r, <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ heck if Revision <br /> may be used for secondary ses Privac law,sl 1 m <br /> I. Application Information-Please Print All Information �} State Plan I.D.Number <br /> Property Owner's Name 1 1 Parcel Number <br /> fePaA /-9e4fo,� 018 - 33,26 `03 - 6 o <br /> Property Owner's Mailing Address /� / Property Location <br /> s- /Ke 1-3e,iOr AJ, S�I' V.//h1%;S 26a T3? N.R/� <br /> City,State Zip Code Phone Number Lot Number 1-0 Block Number <br /> Subdivision Name CSM Number <br /> Ve6s� jV' <br /> H.Type of B ' g(check all that apply) ❑City <br /> 9 1 or 2 Family Dwelling-Number of Bedrooms ❑village <br /> ❑Public/Commercial-Describe Use K1'ownship E 1°fy0/I <br /> ❑State Owned NearestRoad <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 =permit <br /> m 3 ❑ Replacement of 6 ❑ Addition m <br /> SystemTank Onl Exis' S stem <br /> B. ❑ Issued <br /> Permi[Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for Internal use) <br /> 44 LTJ Non-Pressurized In-Ground 21❑ 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 3o❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) WDia Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Posed Rate(Gals./Days/Sq.Ft.) (Min./Inch) i Elevation <br /> �ls7 — y83�`S O 65 3VI.Tank Infoin Total Number Manufacturer Prefab Site Steel Fibef Plastic <br /> Gallons of Tanks Concrete Constructed GlassstingksSeptic or Holding Tank _ Zoog e v <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 /> 76, <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6'S Jy 101lr lien d lfd, <br /> Vill,County/De artment Use Onl <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Age n, re Ps) <br /> )tjApproved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Initial Adverse — it'lf� �O 2- <br /> Determination Determination (J� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete p[am(to the County only)for the system on Pape'not leas then 81/2 x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />