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Safety and Buildings Division Coun <br /> visconsin <br /> MY 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707-7162 Si A cess <br /> De artment of Commerce V <br /> Sanitary Permit Application Sandal Permit Number // <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> ma 78T 33 <br /> be used for second purposes Privacy Law,sl5. IXm <br /> I. Application Information-Please Print All Information State Plan I.D. Number Q ) <br /> Property Owner's Name Parcel Number <br /> s fi (p, 3c�l a� ogg- '79:74 <br /> Property Owner's Mailing Address Property Location <br /> woe A S N. R/T' <br /> City.Stam v /y��/ Zip Code Phones Number Lot Nu ben Block Number <br /> 5 G F, 11,57/ -A / Subdivision Name CSM Number <br /> h4sg �9 SSM Pe ,(U? /54 7 <br /> II.Type of Building(check all that apply) Dory <br /> Yl or 2 Family Dwelling-Number of Bedrooms—'3 ❑Villa e <br /> 8 _ C <br /> ❑Public/Commercial-Describe Use owmhip lG0 <br /> ❑State Owned Newest oad <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 0 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County rue <br /> system I T7Number <br /> ExistingSystem <br /> B• El Check if Sanitary Permit Previously Issued Date Issued <br /> IV.T,,,IIIy---pe of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> ^ <br /> 44 1? Non-Pressurized In-Ground 210 Mound 47 11Sand Filter 50 11Constructed Welland <br /> 22 Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 5l ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Ocher <br /> V.DisersaUTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> O Required Proposed Ram(Gals./Days/Sq.Ft.) (Min./Inch) ,,?D Elevation <br /> 41�144-4Y 7 5o r ? 9—A 4,60 .95. 4 - <br /> 1 13.8 <br /> 9S, 4 - <br /> 93.8 17, <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Galloon of Tanks Concrete Constructed Glass <br /> ew <br /> NE,uau.S <br /> Tanks Tanks <br /> Holding Tank _ <br /> a <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plass. <br /> Plumber's Name(Print) Plumber's ignature MP/MPRS Number Business Phone Number <br /> N S X,7�/7 <br /> lumber's Address(Street,City,State,Zip Code) <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dam Issued Issuing A e t Signature camps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse n5O <br /> Determination �( (N <br /> IX. Conditions of Approval/Reasous for Disapproval <br /> Attach complete plans(to the County only)for the system on paper nor less than al/Z x It Inches in size <br /> SBD-6398 (R. 05/01) <br />