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VA Safety and Buildings UIVISIOn county <br /> 201 W. Washington Ave., P.O. Box 7162 QarnP-f'N� <br /> Wisconsin Madison, WI 53707-7162 Site Address <br /> GC <br /> Department of Commerce d89d3 (31uFFGfc R�1. <br /> Sanitary Permit Application Samury Perrin <br /> Number <br /> In accord with Comm 93.21,Wis.Adm.Code,personal information you provide ILO�� <br /> w be used for second ses PrivacyLaw,sl5. Ixm ❑ Check if Revision L+- <br /> I. Application Information-Please Print All Information State Man I.D.Number <br /> Property Owner's Name ac) <br /> Parcel Number <br /> IY1 ic% si hens 036 yh09 03 800 <br /> Property Owner's Mailing Address Property Local - <br /> 96/7 Rob;, oA/c RSP• u %:S 7 T y0 N,R 17 <br /> City,State Zip Code Phone Number Lot Nbe <br /> umr Blcck.Ni tuber <br /> Subdivision Name CSM Numb, <br /> rntnnefarf,pa MAl -5--al 6-1r- <br /> 11.Type of Building(check all that apply) C) <br /> ,® 1 or 2 Family Dwelling-Number of Bedrooms 3 — <br /> ❑PubliclCommcrc ❑Vdlagciai-Describe Use — <br /> (�1'owmhip unbn <br /> ❑Sum Owned Nernst Ro/a�d <br /> Sju rFL/6 Rj. <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B It applicable) <br /> A. I R New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition ro For County use <br /> -System <br /> Tads Only Existin S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dam Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 JRr Holding Tank 48❑ Single Pass 51 ❑Drip Linc <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Ram(Gals./Days/Sq.Ft.) (Min./inch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Preiab Site Seel Fiber PI: ;tit <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Eauting <br /> Tanks Tanks <br /> Septic or Holding Tank 3000 - �GGQ <br /> Z S�eAt✓ <br /> Dosing Clamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of The POWTS shown on the attached pl¢:ns. <br /> Plumber a Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> /?lam/c /1,P k, s i?„ „�� 7K d J �a-s� 7 is- P6G- vis> <br /> Plumber's Address(Street,City,Sum,Zip Code) <br /> d7>60 N•" ?f w�(t74 wr Ygyp? <br /> VII ount /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui Cut Si lure( c ps) <br /> Surcharge Fee) t <br /> ❑ Owner Given Initial Adverse � � /D �/- <br /> Demrmination <br /> U. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plant(to the Cmaty only)for the system on paper am less than al/2 s 11 inches k af:e <br /> SBD-6398 (R. 05/01) <br />