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Safety and Buildings utvlston county <br /> ` . At201 W. Washington Ave.,P.O. Box 7162 ( W <br /> iseonsin 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 ^� I <br /> may be used for second purposes PrivacyLaw,s s. lxm ❑ Check if Revision 4 <br /> I. Application Information-Please Print All Information g State Plan I.D.Number ------- <br /> Property Owner's NJ(rame �) <br /> N/� Parcel Number <br /> O �'�/t '0o145,-L (S — o - _ Doo <br /> Property Owner's Mailing/Address D Property Location < �� —' <br /> e�0 C C/� �� !i `5'✓!(:S � J T YvN. R�� r� <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> 619 6216 V <br /> �{ 5-q y 9 3 �70 3 Subdivision Name CSIK Numbt <br /> J <br /> II.Type of Building(check all that apply) City <br /> `(1 or 2 Family Dwelling-Number of Bedrooms_ ❑Village <br /> ❑Public/Commercial-Describe Use �(_ 5 C o T <br /> O Township <br /> ❑Statc Owned Nearest Road /l <br /> I/ <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicablt!) <br /> A. 1 ❑ New 2 Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank Only Existitig, 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 on-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wedand <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.Dis ersau I reatment 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) Elevation <br /> 1 47 7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sieel Fiber Pl;,ttic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> ff <br /> Septic or Holding Tank O,0O ( / , O-e— <br /> Dosing Chamber /OO ( V <br /> VII. Resportsibility Statement- 1,the unde ed, a esponsibility for installation of the POWTS shown on the attached phms. <br /> tuber's Name rmq Plu is igna r PRS Number Business Phos:Number <br /> ccs a �cr odd 3K <br /> Plumber's Address Street,Ci State,Zip / <br /> 9 3 J �.,� oC S�o /1 GG ICC � <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dare Issued Issuing Signature Stan ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse �p I��,JJ Jot-/ <br /> 6 <br /> 5 <br /> Detefmination Q� / <br /> I.X. Conditions of ApprovaVReasons for Disapproval <br /> Atmch complete plans(to the County only)for the system on paper not less than 81R s 11 inches in size <br /> SBD-6398 (R. 05/01) <br />