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I Safety and BuddmgS Division s.ounty <br /> ®\ 2Q! W'. Washington Ave., P.O. Boz 7162 83 rneAt <br /> Wisconsin Madison, WI 53707 -7162Siff Address "' <br /> _ Department of Commerce __. 30334 . hx(L� Q, <br /> Sanitary Permit Application Sanitary Permit Number 7 <br /> In accord with Comm 83.21,W is.Adm. Code,personal information you provide8 50 y-1 <br /> El Check if Revision <br /> maused — — <br /> he x <br /> for secondary purposes Privacy 04 Law, s p 4[ 7 <br /> (m) U 5 <br /> 1. Application Information- Please Print All Information State Plan LD. Number <br /> Property Owner's Name Parcel Number V <br /> Il/ For • 03d-- Sd10 - O/9oD <br /> Properly Owner's Mailing Address Property Location <br /> 17{o Sna; Ole Rd. NW a ,vw)f:S 30 Ty/ N. R/S <br /> City,Slate Zip Code Phone Number Lot ONumber Bleck Number <br /> Subdivision Name CSM Numb, <br /> Shoreyreav <br /> N. 4�,C/ L 'so (/. b /? r7 <br /> R.Type of Building(check all that apply) q ❑City _ <br /> 91 or 2 Family Dwelling-Number of Bedrooms ❑Village _ <br /> ❑PubliclCommercial-Describe Use @township <br /> ❑State Owned Nearest Road <br /> W. �rn rlr✓! R aa,1° leaf! <br /> M.T)pe of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicably.) <br /> A' I ❑ New 2 (�Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County we <br /> S stem Tank Only Existing System <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Dale Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 WNon-Pressurized In-Ground 21❑ Mound 47❑ Sand Filter 50❑ Cort,suuucd Wedand <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑ Dnp Line <br /> 45❑ At Grade 46❑Aerobic Treatment Unit 49❑Recircula¢ng 30❑Ocher <br /> V. DispersaUTreatment Area Information: _ <br /> Design Fou (gpd) Dispersal Arca Dispersal Arra Soil Application Percolation Rate Sysmm Elevation Final Grade <br /> Required Proposed Ram(Gais./Days/Sq.Ft.) I (Min./Inch) Elevation <br /> 300 41)-9 43d- . 7 — C1 j <br /> VI. Tank Info Capacity m Total Number Manufacturer Prefab Site Seel Fiber Pi; ;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tank, _ <br /> Septic ar Holding Tank 5;,X _ S0O 7 J�/GO w X( <br /> Dosing CAambcr •L <br /> VD. Responsibility Statement- 1, the undersigned,assume responsibility for installation of the POWTS shown on the attached pl..ns. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Pbor.:Number <br /> /2_.� -/c7¢/l adsSs'/ vis-7 <br /> Plumber's Address(Street, City,Sure, Zip Code) <br /> X7760 -Au v w e6frY�- wr sv8g 3 <br /> VII _Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes GroundwaterDam Issued Issuing co gmture(N ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination 1 <br /> EX. Conditions of ApprovaURessons for Disapproval <br /> Much complete plans(to the County only)ror the system on paper not less than 91/2 a t 1 inches to size <br /> SBD-6398 (R. 05/01) <br />