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Safety and Butlamgs Utvision Uounty <br /> 201 W. Washington Ave.,P.O.Box 7162 �wrn Q t{- <br /> w isconsin Madison.WI 53707-7162 Site Address <br /> Department of Commerce 68 SS Divi iS Lk V� <br /> Sanitary Permit Application sanitary Pdnnit Number 7 <br /> 6ol <br /> In accord with Comm 83.21,Wis.Adm.Code, ( � <br /> personal information you provide Check' Revision ��3 <br /> may be used for Seco ses Privac Law,s15. 1)(m <br /> I. Application Information-Please Print All Information Sate Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> /Cat Pe/r.-sen O�O 43d 7 OS`,OQ 497 <br /> Property Owner's Mailing Address Property ation GV.E (,� <br /> �0 3 GtiriSf�nsovt tris tt 9:S d7 T 90 N.R /6 E <br /> City,State zip Code Phone Number Lot Num r Block Number <br /> Subdivision Name CSM Numbe <br /> tr:�lle m11/, SSy3d 74, 3 —SY /61po <br /> H.Type of Building(check all that apply) [)City _ <br /> ®1 or 2 Family Dwelling-Number of Bedrooms o ❑Village <br /> ❑Public/Commercial-Describe Use OrTownsh p C7i4k/4 snd <br /> ❑State Owned Nearest R Dad <br /> Dw1 Is /Kv 2d <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal use). Complete lit e B if applicable) <br /> A. 1 ❑ New 2.&Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank Only Existing System <br /> B. [) Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,9 Non-Pressurized In-Ground 210 Mound 47[) Sand Filter 50❑ Consi rutted Welland <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. Dispersal/Treatment 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 /> 3d a y.L 5 y3A •7 <br /> 9A. 7 96 v <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sicel Fiber Pl: :[ic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> qNCIWExisting <br /> nks <br /> Septic or Holding Tank 900 <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown.)n the attached pt-ons. <br /> Plumber's Name(Print) Plumber's Signature /MPRS Number Husincss Phono Number <br /> /lick f/s kin )f 4 MP014._5ySte71/4-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776 o Afn <br /> 3s k0ebs>< � W.L- s 8� <br /> rILX. <br /> . Count / t Use Only <br /> pproved oved Sanitary Permit Fee(includes Groundwater Datane l / ,la��t cnt Sigt sure(No Stan ps) <br /> Surcharge Fee) �.oc / �^Given Initial Adverseion <br /> Conditions of Approval/Reasons for Disapproval 41, <br /> /r <br /> g�✓A <br /> <ZAN/, <br /> Attach complete plans(to the County only)for the system on paper not Ins than 81/Z x It inthn in size <br /> SBD-6398 (R. 05/01) <br />