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Safety and Buildings Division County\ 201 W.Washington Ave..P.O.Box 7162 G <br /> consin Madison,WI 53707-7162 Site Addrrss <br /> as <br /> Department of Commerce Sanitary Permit <br /> Number 3 �� 4 <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision ( () <br /> may be used for secondary ses Privacy Law,s15. 1 m State p�I-D.Number V s <br /> I. Application Information-Please Print All Information A/ <br /> Parcel Number " <br /> Property Owner's Name <br /> a_4/ a Property Location OY 7 <br /> Property Owes Mailing Address <br /> T N.R�S� <br /> City,State Zip Cade Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> H.Type of Building(check all that apply) ❑Ctty <br /> IVj or 2 Family Dwelling-Number of Bedrooms (]village <br /> ❑Public/Commercial-Describe Use XTownsbip <br /> ❑State Owned ` jF / •/ �r / Nearest Road Q <br /> III.Type of permit: (Check only one box on line A((n)umbering scheme for inttem2l use). Complete line B if applicable) <br /> A For County use <br /> 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6❑ Addition to <br /> stem Tank Only Existing 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 Non-Pressurized In-Groin 2111 Mound 47❑ San Filar 50❑ Constructed Weiland <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' tment 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 /> q�o 3 7 3 7 tr- /. 2- <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Stcel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Consuuucted Glass <br /> New Existing <br /> Tanks Tanks ` 7 <br /> Septic or Holding Tank - G7/ <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PlumbyFis Name(Print) Plum Signaaue MP/hfPRS Number Business Phone Number / <br /> Y <br /> i s Address(Street.City,State,Zip e) _ <br /> VIII.Count /De artment Use nn1 <br /> Sanitary Permit 1' ('includes Groundwater Date Issued Issuing a Si re(NS Ps) <br /> 0-*—Pproved ❑ Disapproved - Surcharge Fee) <br /> ❑ Owner Given Initial Adverse ayg <br /> 1/ <br /> Determination <br /> EK. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plana(to the CounO adr)far the antem on WPr+not leo than aln x ll laches m dze <br /> SBD-6398 (R. 05/01) <br />