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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 G! <br /> Madison,WI 53707 -7162 Site Address <br /> isconsin <br /> De artment of Commerce Sanitary Permit Number p ` <br /> Sanitary Permit Application In accord with Comm 83.21,Wis.Ad [Im.Code,personal information you provide Check if Revision <br /> may be used for seen ses Privacy Law,115. 1 in Stau Plan I.D.Number v1 <br /> FroperNa, <br /> n Information-Please Print All Information <br /> Parcel Number W <br /> 's Name <br /> d A1-d � 3� 7 3 <br /> Property I.ocationp <br /> i s Mailing Address <br /> `�' N,R <br /> Phone Number Lot Number Blocksr <br /> Zip Code Subdivision Name CSM Number <br /> u � �x uil ' g(check all that apply) ❑City <br /> Alor 2 Fancily Dwelling-Number of Bedrooms <br /> ❑Village <br /> ❑Public/Commercial-Describe Use e �/s� <br /> Nearestst Road � <br /> ad C� <br /> ❑SStateOwned S Cr^0 , I��1f <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 3 ❑ Replacement of b ❑ Addition to <br /> For County use <br /> 1 ❑ New 2 K Replacement System <br /> S sum Tank Onl Exis' S sum <br /> B. [I Check if Sanitary Permit Previously Issued <br /> Permit Number Dau Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,Non-Pressurized In-Ground 21E] Mound 47❑ Sand Filter 50 11 Constructed Wetland <br /> 22 El Pressurized In-Ground <br /> 41 ❑ Holding Tank 48 El Single Pass 510 Drip Line <br /> 45❑ At-Grade <br /> 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 Rau Sysum Elevation Elevation <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) <br /> �/s0d �3 G y� / 7 7y, 7 <br /> VI.Tank Info CapaciN <br /> ty in Total umber Manufacturer Prefab site Steel Fiber Plastic <br /> Gallons Gallons N Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks ,,/ /— <br /> Septic or Holding Tank /Dc, - `de2C,) / /(s'©/�W N r rJ <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown oil the attached plans. <br /> Plumber's Signa �2�ture MP/MPRS Number Business Phone Number <br /> Plumber's Name,) / <br /> —,7 <br /> �� <br /> "ale �'u� 1e1117G��u <br /> Plumber's Address(Street,City.State,Zip Code) <br /> V1II. County/Department Use Onl <br /> Sanitary Permit,�ee(includes Groundwater Dau Issued Issuing Agent S' o Stamps <br /> ved ❑ Disapproved Surcharge'lee)p,) <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the rystem on per not tem man 8112 x it Inches in size <br /> SBD-6398 (R. 05101) <br />