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Safety and Buildings Division Coun <br /> 201 W. Washington Ave.,P.O. Box 7162 figs P/ <br /> ME Madison,WI 53707 -7162 Site Address / <br /> Department of Commerce am w <br /> Sanitary Permit Number , 1 <br /> Sanitary Permit Application d <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision 4 79 4 7 <br /> may be used for secondary purposes Privac Law,s15.04 1 m) O , <br /> I. Application Information-Please Print All Information � �( - State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> C /(}� <br /> eY �o d ( Oda 6r —:2576 <br /> Property Owner's Mailing Address Property Location <br /> It1E S6N t'tb:So?s T�eO N, RIC <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> ,- <br /> II.Type of Building(check all that apply) ❑City <br /> �171 or 2 Family Dwelling-Number of Bedrooms �2 ❑Village <br /> ❑Public/Commercial-Describe Use e — ownship <br /> ❑State Owned Nearest Road <br /> a 973 <br /> 111.Type Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> For County use <br /> A <br /> 1 ❑ New 2 Replacement System 1 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem 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-A Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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. Dis ersal/Treatment Area Information: Final Grade <br /> Design Flow(gpd) Dispersal Area Dispersal Area Sod Application Percolation Rate System Elevation ElevationRequired Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) <br /> 19 91Vd <br /> Z/� 9 �3-�5 � � 9�Q <br /> VI.Tank Info Capacity in Total Number Manufacturer PrefConca Constructed Steel SiteGlass <br /> bePlasic <br /> Gallons Gallons of Tanks <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Dosing Chamber O <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Signature MPlMPRS Number Business Phone Number <br /> Plumber's Name(Print "I� !/� _�2Y� <br /> 1,(>A-de ��s �Iftil (.t�,4 ; 2 z70l 3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 8o fi S/¢ rc h W L S T-,p <br /> VIII. Count /De artment Use Only Sanitary Permit Fee(includes Groundwater Date Issued Issuing Age ignamre(No s) <br /> Approved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Initial Adverse,S� r <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> poach complete platin(to the County only)for the system on paper not leas than 81/2 x 11 Inches In size <br /> SBD-6398 (R. 05/01) <br />