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Safety and Buildings Division County A i <br /> 201 W. Washington Ave.,P.O. Box 7162 f At e <br /> Npisconsin Madison,WI 53707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide i SQ V <br /> may be used for secondarypurposes PrivacyLaw,sl5. 1 m) El Ch k if <br /> Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> ,zh / k' azo 4302 0 <br /> Property Owner's Mailing Address Property Location //'',,,9 <br /> Q �//V 'R 'A;S 1Z T 1kN,R j E <br /> City,State Zip Code Phone Number Lot Number <br /> 1 L. I i <br /> Subdivision Name CSM Number. <br /> lvollive G 6/ZA4S WZ -9r87 V 3 <br /> rIII.Type of Building(check all that apply) ❑Ci <br /> �q ty <br /> 1 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑ Public/Commercial-Describe Use 90township © l <br /> ❑State Owned Nearest Road <br /> 6V# 7t <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. I New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S tem Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued I Permit Number Dam Issued <br /> Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Non-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) 9.S:Z Elevation <br /> 45 D y00 9� _ 9r.r 9 y 2 <br /> S 9q.1 ,. 12.6 97. 5'- <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank f000 _ 000 LJCAJ <br /> Dosing Chamber I o <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 /> c4me.p z2S$S I 7/S S66- 4157 <br /> inbei s Address(Street,City,State,Zip Code) <br /> Z7 7 (a o /4w 35 tEosrm �4$ 3 <br /> VIII. County/ eartment Use Ohly <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issu' g <br /> Surcharge FeeAgent Signature(No Scamps) <br /> Approved El Disapproved ),yt, ///yyy {.�' <br /> ❑ Owner Given initial Adverse 'y'� 1_✓v� i ,f <br /> Determination -- ` <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> -U <br /> 3E _ 4 2002 1 <br /> BURN <br /> Attach complete pians(to the County only)for the system on paper not less than 81/2 x II Inches in saZONING <br /> G <br /> SBD-6398 (R. 05101) <br />