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Safety and Buildings Division County <br /> A an 201 W. Washington Ave.,P.O. Box 7162 ftodfl(' <br /> Ivisconsin <br /> Madison,WI 53707 -7162 Site Ac3dress <br /> Department of Commerce oV&1 I <br /> Sanitary Permit Application Sanitary Permit Number <br /> 7 a 3�Oa <br /> in accord with Comm 83.21,Wis. Adm. Code,personal information you provide El Check if Revision <br /> may be used for second purpose PrivacyLaw,s15. 1 m) <br /> I. Application Information-Please Print All Information ^ j a State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> /A6F,r S DI Z 9110 0/ /00 <br /> Property Owner's Mailing Address Property Location n <br /> 91 C F tjF#41 ti .4;S y7r <br /> T * N,R �S <br /> City,State Zip Code Phone Number Lot Number Block Number i <br /> 6,51-IV-946 <br /> �OOD ��• 5511Subdivision Name CSM Number <br /> biz- /939 LJK,,,,, _L1;, <br /> H.Type of Building(check all that apply) ❑City <br /> ,91 or 2 Family Dwelling-Number of Bedrooms a <br /> ❑Village <br /> i <br /> ❑ Public/Commercial-Describe Use 3*ownshipJ_7{Gsk3Qf <br /> ❑State Owned Nearest Road <br /> kovA��k <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1%New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> System Tank Onl Exis' S stem <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*!t 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.D' rsal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Firm Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Qd a EI nation <br /> 45vx,43 (0¢8 • 7 --� 90? 4b0. <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site r Plastic <br /> Gallons Gallons of Tanks Concrete Constructedlass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank f/�o �—:___T1QB0 <br /> Dosing Chamber l <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 1-hl Pr-1 fzzSg s i is- 566- 415 <br /> t�lumber'sAddressStreet,City.State,ZipCode) <br /> 400 f+w �S66 ,artment Use 1Sanitary Permit Fee(includes Groundwater Date Issue Issuing Agen Signatu (No ps) <br /> Disapproved Surcharge Fetes /11 <br /> Owner Given Initial Adverse �Jtermination ' VL-Approval/Reasons for Disapproval <br /> l 2002 <br /> R - <br /> Attach complete plans(to the County only)for the system on paper not less than 811ZZx-1 I ificM Wo <br /> SBD-6398 (R. 05/01) <br />