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Safety and Buildings Division county <br /> 201 W. Washington Ave.,P.O. Box 7162 rn l f f- <br /> iseonsin Madison,WI 53707-7162 Site Addres <br /> Department of Commerce /3 O Garcon <br /> Sanitary Permit Application Sanitary Pe Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> ma used ❑ Check i Revision `CJS �Z 5 <br /> be for secotd Purposes Privacy Law ,s15.04 l$m <br /> I. Application Information-Please Print All Information fSum PtanI.D. Number r-y <br /> Property Owner's Name <br /> Parcel m Nur J <br /> /ee,f7th a- Drage 04,.. Ne,/l &CL S'- 4//),-0A-9Ac0 <br /> Property Owner's Mailing AddressPropenY don �/q,, <br /> 30a(yS. 3/sf. sfrea7< u 14;S 1A T 40N.R /Y <br /> City Sam Zip Code Phooe Number Lot Number <br /> Bieck:lumber <br /> Subdivision arTu CSM Numbe <br /> L.e.- Grosse wt Sybo/ Gob- 78P y3yr '066 V.10 P,/ro <br /> II.Type of Building(check all that apply) ❑City <br /> a I or 2 Family Dwelling-Number of Bedrooms — <br /> ❑Village <br /> ❑Public/Commercial-Describe Use p SGa 774 <br /> 1�7'ownshi <br /> ❑State Owned Nearest Ro <br /> Ca r{en /?rg <br /> Ill.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B it applicable) <br /> A. 1 R New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑Addition to For County use <br /> s <br /> S sum Tank Only Existing System ' <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number am Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 J9 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Construc ted Welland <br /> 22❑ Pressurized In-Ground 41❑ Holding Tank 48❑ Single Pass 5l ❑Drip Li <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 Mea Soil Application Percolation Rate Syst m Elevation Final Grade <br /> Required Proposed Ram(Gals./Days/Sq.Ft.) (Min.1 nch) y 7 Elevation <br /> It 45? <br /> 3 od loao 600 s - r. 7 5'x. 7 <br /> E_ Statement <br /> tCipacuymTotal Number Manufacturer Prefab Site S,cel Fiber PI: xie <br /> Gallons of Tanks Coracle C structed Glass <br /> ank 800 'f <br /> Z S/CA aa. �c <br /> ility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on t c attached pl::ns. <br /> s Name(Print) Plumber's Signature MP/MPRS Number BusinessPhon:Number <br /> gs/ 7CS- S-66- 4/s7 <br /> Plumber's Address(Street.City.State,Zip Code) <br /> ,ol 77662 Ie/r... 3r w -bs+` li/s S <br /> . Count /De artment Use Only <br /> !Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dau issued Iswing Signature(N au ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adveru `O S - <br /> Determinauon <br /> IX.Conditions of Approval/Reasotu for Disapproval <br /> Attach complete plans(to The County oaly)for the system go paper nq Iess than al/2 s II iochm size <br /> SBD-6398 (R. 05/01) <br />