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Safety and buildings Division county <br /> 14 201 W. Washington Ave., P.O. Box 7162 �Ga✓K P jT— <br /> r►seonsin Site Address <br /> Madison,WI 53707-7162 -----. <br /> Department Of Commerce 3581 P�hn/rsu/� ?� <br /> Sanitary Permit Application Sanitary Permit Numbcr <br /> EApplication <br /> rd with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> ma be used for seco purposes PrivacyLaw,s15. t)(m ❑ Check if Revision <br /> formation-Please Print All Information Spee Plan LD.NumberAl <br /> 1 !`✓-' <br /> Property Owner's Name <br /> Parcel Number �-- <br /> /Y7 ik e j r,, ,, 01�-4�366-Opb <br /> Property Owner's Mailing Address Property Location �- <br /> -7� V L) rham son v4v-e /� t Aoy ( .. (�� � <br /> City,State Zip Code Phone Number [I !i;S 3b Ty0 N, R /� E <br /> Lot Number Black,lumber <br /> Subdivision Name C�be <br /> S. <br /> se 1P. I m N. Sao>s 6,5-/_ y.rs - Sod/ V� <br /> II.Type of Building(check all that apply) <br /> 91 or 2 Family Dwelling-Number of Bedrooms ?` (3Ctty <br /> ❑Public/Commercial-Describe Use ❑Village _ <br /> ❑State Owned <br /> Township J4c-lcson <br /> Nearest Road <br /> Pcr/r//vlJa/A <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal use). Complete line B if applicabl(.,) <br /> A 1 ❑ New 2 4 Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> _System I Tank Only Existing System <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 M Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <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. Dia ersaUTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil ApplicationPercolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Fr.) (Min./Inch) Elevation <br /> 300 ya-9 y3� . 7 — S <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Sigel Fiber <br /> Gallons Gallons of Tatilcs PI: iuc <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> Septie or Holding Tank /000 - /Ooe ,Z <br /> /Uorw Pse v ,�- <br /> lbsing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached phos. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number <br /> Business Pbon:Number <br /> l � � / <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII. Count /De artment Use Onl <br /> ❑ Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signatur o Stat ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adveru C,\'O 11046 n J_/6 <br /> Detetmittadon r7(J /y/W4 <br /> M. Conditions of Approval/Reasons for Disapproval <br /> Attach complete pians(to the County only)for the system on paper not less than 31/2,%11 inches in size <br /> SBD-6398 (R. 05/01) <br />