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201 W. WashingtonAve•, <br /> P.O.Box7162 6%r r) e f f 1 <br /> iseonsin Madison.WI 53707-7162Site Address <br /> Department of Commerce <br /> I <br /> Sanitary Permit Application Sanitary F.erttlit Nualber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes IrI Law,:15.04(1)(m) ❑ Check if RevisionLj <br /> L�3 C� 0�6 <br /> roperty <br /> I. Application Information-Please Print All Information )L q State Plan I.D. Number <br /> POwner's Name �{ Parcel Number 1 <br /> Jerr l�uulus Od g333 <br /> Property Owner's Mailing Address <br /> /?U Property Location <br /> NE <br /> City,State Zip Cade Phone Number -5W!�S4 u:S 33 T °/D N,R 4 <br /> r lock Number <br /> 4oVT d► LOt. <br /> I <br /> Websfir- W-r jye.73 7rs= vu 8736 SubdivisioaName CSM Number <br /> II.Type of Building(check all that apply) <br /> F7.3 <br /> v. :z Pdata. /9 <br /> Z I or 2 FamilyDwelling 3 Claryry <br /> tlg-Number of Bedrooms <br /> C3Public/Commercial-Describe Use e 0 <br /> ❑State Owned WTownship O/}�_(4N of <br /> Neatest Road <br /> stone : ad. j <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for interna!use), Complete line B if applicable) <br /> A. 1 New 2 ❑ For C tate <br /> Replacemem System 3 ❑ Replacement of 6 ❑ Addition to County <br /> stem Tank OnI Exis' system <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV,Type of Permit: (Check all that a 1 ng <br /> pp y)(aumberi scheme is for internal me) <br /> 44® 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❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersalfrreatment 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) <br /> J!"0' <br /> 700 9 00 s Elevation <br /> VI.Tank Info Capacity in Total Number I Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Tanks Plastic <br /> Concrete Constructed Glass <br /> New Existing I ' <br /> Tanks I Tanks <br /> Septic or Holding Tank /W _ X000 5 kdW i 1 <br /> Dosing Clamber <br /> I i <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 <br /> rss Phone Number <br /> s$S I 5 g66- 4lS7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2.7 7 (o oN)T <br /> . X48 3 <br /> I. County/De artment Use Ofil <br /> i <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing nt gnature! o mps) <br /> Surcharge Fee) �f <br /> 13 Owner Given Initial Adverse Q( Lam <br /> Determination �-fP (/�(J(1 V lJ II" �lTl/J <br /> IX. Conditions of ApprovaUReasons for Disapproval <br /> I <br /> Attach complete Ilam(to the County only)for the system on paper not leas than 8112 x 111 is size <br /> SBD-6398 (R. 05101) <br />