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Safety and Buildings UIVISIOn eounry <br /> W201 W. Washington Ave., P.O. Box 7162 isconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce ld5 7 L; RjL 4ae-',J 4.1, <br /> Sanitary Permit Application Sanitary Permit Kumber <br /> Uj <br /> In accord with Conus 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> my be used for secondary purposes Privacy hw,s15.04 D(m) - <br /> I. Application Information-Please Print All Information State Plan I.D.Number n <br /> 4y KtUtPrJ <br /> Property Owner's Name / Parcel Number 024-3P3. 2m <br /> e LerCO,�3q'; D7- Z - -39-I / 5 es -a/pty <br /> Property Owner's Mailing Address Property location <br /> -7080 9q19 6¢- a u:S 13 T 39 N, R /'/ W <br /> City,State Zip Code Phone Number Lot Number(50Vf. Black Number <br /> SA04 old I A/ 1/ -5'6 Subdivision Name CSM Numbe <br /> �rII..Type of Building(check all that apply) 7 l(' 7 b Dory <br /> to _ <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village <br /> ❑Public/Commercial-Describe Use Township �usK <br /> ❑State Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal use). Comple a line B if applicabb^) <br /> A. 1 per•New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I Tank Only Existing System . <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Dare Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,X Non-Pressurized In-Ground 2111 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.Dispersal/Treatment Area Information: <br /> Design flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System El Final Final Grade t7 <br /> Required //�� Proposed // Ram(Gals./Days/Sq.FQ (Min.Anch) j��l-,�( =cv -3 Elevation-k/=9 <br /> Y50 03 i t 3 tf 7 Tid <br /> '�' '�' rt = 9y.0 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Si cel Fiber PI: ;tic <br /> Gallons Gallon of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septi or[toldtna Tank /,000 <br /> Dosing chamber <br /> coo _. <br /> kPlumbWer*s <br /> esponsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached pli,o . <br /> 's Name(Print) Plumber's Signature MPIMPRS Numbcr Busts s Pborrs Number <br /> �� 3o 8yy f7, 635 &iSAddress(Street.CityState,T Code) <br /> 7o 5 ( > . �w S truer `/80Count /De arm-- Use Onlroved ❑ Disapproved Sattitary Permit Fee(includes Groundwater Date Issued Issuing A Signature an ps) <br /> Surcharge Fee) �. <br /> ❑ Owner Given Initial Adverse -3;Z5 13M <br /> Dttetminadon <br /> Ma Conditions of ApprovalfReasous for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not Im than 81/2 a 11 Inches in sue <br /> SBD-6398 (R. 05/01) <br />