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Safety and Buildings Division Cou"E <br /> Mrseonsin 201 W.Washington Ave., P.O.Box 7162 urnQ <br /> Madison,WI 53707-7162 Site Address <br /> Department of Commerce _TBWL Il,`mt GI ' <br /> Sanitary permit Application Sanitary Permit umber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 5 0 3 <br /> rna beused for second ses PrivacyLaw,s15. 1 (m Check if Revision <br /> I. Application Iluormation-Please Print All Information <br /> State Plan I.D.Number <br /> Property Owner's Name <br /> Parcel Number <br /> o ao-�3aa-oa-5cx� <br /> Property Owner's ailing Address <br /> 'l` Property Location <br /> D x <br /> City.State w I I :Som T40 N.R <br /> Zip Code Phone Number Lot Number Block Number <br /> I Subdivision Name CSM Number <br /> II.Type of Building(check all that apply) <br /> or 2 FamilyDwell' ❑Cnty <br /> Dwelling-Number of Bedrooms <br /> ❑Public/Commercial-Describe Use ❑Village <br /> ❑State Ownedownship <br /> Neaad <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line f applicable)� <br /> A. <br /> f <br /> ew 2 11 Replacement System 3 11 Replacement of 6 El Addition to For County use <br /> S stem Tank On[ -xis' S stem <br /> B• Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV. 1 Ssf c3(o <br /> Type of Permit: (Check all that a 1 <br /> pp y)(nttmbering scheme is for internal use) <br /> 441<�on-Pressurized In-Gfound 210 Mound 47❑ Sand Filter <br /> 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass <br /> 8 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30 13 Other <br /> V.Dis ersai/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal AreaSoi!Application <br /> Required proposed Percolation Rate System Elevation Final Grade <br /> Rane(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> (ot-�'� (053. I •� — `�to.5 qg.S" <br /> VI.Tank Info Capacity in Total Number Manufacturer <br /> Gallons Gallons of Tanks Concrete <br /> Site Steel Fiber plastic <br /> New Existing Contrera Constmcted Glass <br /> Tanks Tanks <br /> Septic r Holding Tank `�� 1 <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plats. <br /> Plumber's Name(Print) P tuber's Signa e <br /> MP/MPRS Number Business PhoneNumber <br /> is LA(0 b a <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Cotmt /De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(inc lud s Groundwater Date Issued Issuing gent Signature(No Stamps) <br /> barge . �� <br /> ❑ Owner Given Initial Adverse /0-o- <br /> Detemtination VV l <br /> 1X. Conditions of Approval/Reasons for Dis proval <br /> fin <br /> VVT 9 <br /> Attach Complete plans(to the Coanq o y o han 81/2 x 11 Inches In size <br /> SBD-6398 (R. 05101) � ZONING J <br />