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*sconsin <br />Safety and Buildings Division <br />201 W. Washington Ave., P.O. Box 7162 <br />Madison, WI 53707 - 7162 <br />County <br />cv /� �i <br />Site Address <br />a <br />10 <br />� <br />Department of Commerce <br />Sanitary Permit Application <br />Sanitary Permit Number <br />�� <br />In accord with Comm 83.21, Wis. Adm. Code, personal information you provide <br />❑ Check if Revision <br />- <br />may be used for secondary purposes Privacy Law 15.04(1)(m)State <br />/ <br />I. Application Information - Please Print All Information//-, <br />4 <br />Plan I.D.Number <br />Alk <br />Parcel Number <br />Property Owner's Name <br />/ <br />i�9/Yl <br />/ 5' '321 G vio <br />Property Owner's Mailing Address <br />Pro rty Location <br />N4 'A'A;Sa��1 T3% N,R16 <br />City, State <br />Zip Code <br />Phone Number <br />Lot Number Block Number <br />Subdivision Name CSM Number <br />H. Type of Building (check all that apply) <br />❑City -� <br />9k or 2 Family Dwelling - Number of Bedrooms <br />❑Village <br />wnship ��✓ '`� <br />❑ Public/Commercial - Describe Use — <br />Nearest Road <br />❑ State Owned <br />III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br />A <br />1 ANew <br />2 ❑ Replacement System <br />3 ❑ Replacement of <br />6 ❑ Addition to <br />For County use <br />System <br />Tank Onl <br />Existina 5 stem <br />B. El Check if Sanitary Permit Previously Issued <br />Permit Number <br />Date Issued <br />IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br />44 Ion -Pressurized In -Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wedand <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. Dispersal/Treat ent Area Information: <br />Design Flow (gpd) <br />Dispersal Area <br />Dispersal Area <br />Soil Application <br />Percolation Rate <br />System Elevation <br />Final Grade <br />Elevation <br />Required <br />Proposed <br />Rate(Gals./Days/Sq.Ft.) <br />(Min./Inch) <br />y <br />VI. Tank Info <br />Capacity in <br />Gallons <br />Total Number <br />Gallons of Tanks <br />Manufacturer Prefab Site Steel <br />Concrete Constructed <br />Fiber Plastic <br />Glass <br />New Existing <br />Tanks Tanks <br />Holding Tank <br />Septic or <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) // <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />Plumber's Address (Street, City, State, Zip Code) <br />'t,fo�y <br />VIII. Count /De artment Use Only <br />Approved <br />El Disapproved <br />Sanitary Permit Fee (includes Groundwater <br />Surcharge F <br />d <br />Date;6- <br />Issuing Age t Signature No tamps) <br />❑ Owner Given Initial Adverse <br />�� <br />� <br />Z <br />Determination <br />IX. Conditions of Approval/Reasons for Disapproval <br />Attach compiete puns do the %-ounty omy/ zor we system on paper nut .coo .,.�.. o.,� ., ....,....w ... �...� <br />SBD -6398 (R. 05/01) <br />