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Safety and Buildings Division Couny <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> Visconsin Madison, WI 53707 -7162 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application Saruary Permit Number <br /> In accord with Corms 83.21,Wis.Adm. Coda personal information you provide O Check if Revision /476,537 --�. <br /> my be used for secondary purposes Privacy Law 15. I1 'm <br /> I. Application Information-Please Print All Information r�l l State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> 0 0 0 4 a Stx� <br /> Property Owner's Mailing Address Property Location 6e1 <br /> 14 'A;SlT C/ N,R17 <br /> City,State Zip Code Phone Number Lot Number Black Number <br /> CSM Number <br /> d 5_5W-2 so 7 mss/ Zflft <br /> II. Type of Building(check all that apply) OCity <br /> 7111 or 2 Family Dwelling-Number of Bedrooms Village <br /> O Public/Commercial-Describe Use —� ownship .e) <br /> O State Owned Nearest Road/ <br /> O 4 /(150/0 /P <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for Internal use). Complete line B if applicable) <br /> A. I' LNew 2 Repiacernem System 3 O Replacement of 6 O Addition to For County use <br /> S stem Tank OnlyExis' S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 i�1.4on-Pressurized In-Ground 210 Mound 47 11 Sand Filter 50 O Constructed Worland <br /> 22 O Pressurized In-Ground 41 O Holding Tank 48 O Single Pass 5111 1 Drip Line <br /> 45 O At,Gmde 46 11 Aerobic Treatment Unit 49 O Recirculating 30 O Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> SSD 5'3 so /_ 7 9s0 970 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> TeNcs Tanks — <br /> Septic or Holding Tank ]`— <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the tmtkrsigoed,asstrme rcsponsibWty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> w �e >�X / z7�s �y9-.7 <br /> Plumber's Address(Street,City,Sate,Zip Code) <br /> 'U Ox S>f (f n) <br /> County/De artment Use Onl <br /> Satuary Permit Fee(includes Groundwater Dale Issued Issuing Agent Signature(No Stamps) <br /> Approved O Disapproved <br /> Surcharge Fee) <br /> O Owner Given Wtial Adverse. <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not leu than gl/2 x 11 lochea to alae <br /> SBD-6398 (R. 05101) <br />