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Safety and Buildings uivision t:ounty <br /> 201 W. Washington Ave.,P.O. Box 7162 $arn�17` <br /> `�SC011 LSin Madison, WI 53707-7162 SitTAddirc; <br /> Department of Commerce �aaSCu LK �rwr <br /> Sanitary Permit Number <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> may be used for secondary purposes Privacy Law,sl .04 Win State Plan I.D.Number <br /> I. Application Information-Please Print All Information <br /> Parcel Number v <br /> Property Owner's Name <br /> 0 8 - C71,cb -pit roo <br /> �kdfY Suth Cr6M,/ <br /> Property Owner's Mailing Address Property Location <br /> J 8966 f/ans6uen L/G rpt•-r +s u:S 7 T N.R/Y E <br /> City,State Zip Code Phone Number Lot Number Bleck Number <br /> /� <br /> Subdivision Name CSM Numbe <br /> 06 n bury <br /> IT.Type of Building(check all that apply) ❑City _ <br /> R 1 or 2 Family Dwelling-Number of Bedrooms 01N ❑Village _ <br /> ❑Public/Commercial-Describe Use ffTownship .Sea h` <br /> ❑State Owned Nearest Road <br /> H�tns�arn L/� Trwr <br /> III.Type of Permit: (Check only one box online A(numbering scheme for.internal use). Complete line B if applicablt:) <br /> A1-6 <br /> For County use <br /> 1 ❑ New 2.�Replacement System 3 ❑ Replacement of ❑ Addition to <br /> system Tank Oril Existio S stem <br /> B. ❑ Check if Sanitary Pertnit Previously Issued <br /> Permit Number Dace Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44V 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❑ Ac-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Soil Application Percolation Race System Elevation Final Grade <br /> Design Flow(gpd) Dispersal Area Dispersal Area <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> Soo 600 600 7 _ 93 q 7G.3 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Si eel Fiber PI:.;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding TankSieO 80(J .Z .S•&If <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached ph as. _. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> Rick #a h,n s <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .1 77ao aci 3S We65+4rr l fJs' SSSS 93 ----- <br /> VIII. Count !De artment Use Onl tan s) <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A t Si tune( P <br /> Surcharge Fee) ,{ <br /> ❑ Owner Given Initial Adverse 7ti Z5D 116 <br /> Determination �f <br /> IX. Conditions of ApprovalfReasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than E113 x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />