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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 <br /> FSCQnS n Madison, wI 53707-7162 r <br /> ,r ■ Site Addrtss o R� <br /> Department of Commerce <br /> Sanitary Permit Application Salutary Permit Number r�-) <br /> ' In accord with Comm 83.21,Wis.Adm.Code, _,1 <br /> may be used for secondaryiva Ll information You provide �J nQ y O <br /> ses Privy Law,s15. 1 m ❑ Check if Revision ,7 7V L <br /> I. Application Information-Please Print All Information <br /> State Pan I.D.Number <br /> ProPenY Owne; tame6 C lParcel Number <br /> � <br /> Prope ! wIX�r,Mailing Address <br /> Pr pe- <br /> ' G ...Property Location ```` <br /> City,State Zi Code 1A.S T 7�N,R� <br /> P Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> MAI lC? tG� <br /> II, oP Buil ' 7i 5 7S'(o 9 7S� <br /> Type (check at app <br /> ❑ 1 or 2 FamilyD ' � try <br /> welhng-Number of Bedrooms <br /> ❑Public/Commercial-Describe Use ❑village <br /> ❑Sate Owned 2%w'rtship s <br /> Nearest Road <br /> t � � <br /> M.Type of Perm!(.- (Check only one box on line A(numbering scheme for internal use). Complete line B if app ble) <br /> A. 1 ❑ New 2 T M lacement P <br /> P System 3 ❑ Replacement of 6 ❑ Addition m For County use <br /> S stem Tank ExistingSystem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> If Type of Permit: (Check all that apply)(ni mbering scheme is for internal use) <br /> 44;`Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter <br /> 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41❑ Holding Tank 48❑ Single Pass <br /> 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 Required Area Ms Pro sed Ana $oil A lira'on <br /> PP Percolation Rale System Elevation Final Grade <br /> Po Rate(Gals./Days/Sq-Ft.) (Min./Inch) <br /> Elevation <br /> rb <br /> VAK <br /> VI.Tank Info Capacity inTotal Number Manufacturer Prefab Site <br /> Gallons Gallons of Tanks Steel Fiber Plastic <br /> t New p-,.,;__ Concrete Constructed Glass <br /> Tama Tarda <br /> Septic or Holding Tank _ �,y1 /`� <br /> Dosing Chamber v W <br /> VII.Responsibility Statement- I,the undersigned,ttsstmme responsibility for tion of the POWTS shown on the attached plans. <br /> P ten's Name(Print) Plttr's Sig MP RS Number <br /> Business Phone Number <br /> 1Cltar (,e) 7/S�G3S' 875 2 <br /> Pluglper's Address(Street,City.Sate,Zip Code) <br /> (��') /�d n �_7 &6 0�1 t� c r/ S'�{8C) <br /> Corm /De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued 'Issu' ge Signam o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IR. Conditions of Approval/Reasons for Disapproval <br /> 09 <br /> LJ <br /> Attaeb eompkte plans(to the County only)for the System on paper not Iw tban 81/2 s 11 laha In sat j, <br /> J � I <br /> SBD-6398 (R. 05101) BURNE <br /> ZONING COUNTY <br />