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Safety and uundmgs urvlsion bunt, <br /> �f �, 201 W. Washington Ave., P.O. Box 7162 u 2 __ <br /> Wisconsin Madison, WI 53707 -7162 Site Address "-- <br /> Department of Commerce _ <br /> Sanitary Permit Application Sanitary P<rtnit Numne ---In accord with Cc=83.21.W is.Adm. Code,personal information you provide Check if Revision `1' I U J,I q Q 52 <br /> may be used for secondary purposes Privac Law, x15.04 1)(m) ❑ <br /> I Applin tion Information-Please Print All Information Sure Plan LD. Number <br /> Property Owner's Name Parcel Number <br /> 7✓l Z 907 0/ z«� <br /> Property Owner's Mailing Address Property Location <br /> ZO�� ZSTth`'� A A:S / T1/ON. R /SE <br /> Ciry,State Zip Code Phone Number Lot Number^ BIC ck Number <br /> Subdivision Name CSM IN, <br /> M/22190 C, �✓ Sol C5 m\ I nl <br /> )S.Type of Building (check all that apply) ❑Ciry <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑PublidCommercial-Describe Use _ Township SiDN <br /> ❑State Owned Nearest Road <br /> N r <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicabl.) <br /> A. I New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Ord <br /> ExistingS stem <br /> B. ❑ Check if Sanitary Permit Previously Issued PC_,Number Dare Issued <br /> _V Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ( Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wedand <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑ Dnp Line <br /> 45❑ At Grade 46❑Aerobic Trcatment Unit 49❑Recirculating 30❑Olhcr _ <br /> V. DispersaVTreatment Area Information: _ <br /> Design F'.ow (gpd) Dispersal Arca Dispersal Arra Soil Application Pcrcolmion Rata System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Fr) (Min./lnch) 'op 475 Elevation ge} 5- <br /> G�8 . - 7 ae M ges- <br /> q�,s <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber PI: aic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Eslsnng <br /> Tanks Tara,,Septi<or HoldingTank loco _ <br /> oeain;crit ntt GOD <br /> VU. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POW"ES shown on the attached pl.n9. <br /> Plu bet's Name(Print) Plu er's Signature MP/MPRS Number Business Phon:Number <br /> r idAQ I" I Adij ' ze66 ,,W <br /> Plumber's Address(Street, ity,Suite, Zip Code) <br /> 27760 74- <br /> 1. Count /De p rtment Use Only <br /> Appmved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issin gen'. Signa (No Star ps) <br /> Surcharge Fee) s1 4 /^�J - <br /> ❑ Owner Given Initial Adverse �5 is rl <br /> Determination '-� o(q(_ <br /> LY. Conditions of Approval/Rea5ons for Disapproval <br /> AU6 1 92005 �� <br /> Attach complete plata(w the Courcy oely)fo a srBOpllpesff 1"INI inches io nue <br /> SBD-6398 (R. 05/01) ZONING <br />