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Safety and Buildings Division County <br /> Visconsin <br /> 201 W. Washington Ave., P.O. Box 7162 Madison,WI 53707-7162 Site Address , <br /> Department of Commerce of V2 <br /> Sanitary Permit Application San nary PermitBNu/`mfber <br /> In accord with Comm 83:1,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) <br /> I. Application Information-Please Print All Information State PlI.D. umber <br /> Property Owner's Name Parcel Number <br /> -r"0 P - (� - 1^1 1 5 C a l✓S'14/ L, bO I 01 3 3 3 - �;z�� d <br /> Property Owner's Mailing Address Property Location <br /> 3 1 7 v ig+ 5 L -A 4:S / JT-3i7 N.R�C E <br /> City,State Zip Code Phone Number Lot Nymber Block Number <br /> Seo n C_ I � �,' _� p} — Subdivlision Name CSM Number <br /> J l V(0 Al8 <br /> II.Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms <br /> ❑V01age <br /> Public/Commercial-Describe Use /T� ce , t �4- m,,,ownship M*I'toel <br /> Fav <br /> State Owned Nearest Road <br /> t-I✓ 3S' <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete I' e B if applicable) <br /> A. For County use <br /> I New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank Only Existing System <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 ❑ Non-Pressurized Tn-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 t-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Gmde <br /> a/ Required Proposed Rate(Gals./Days/Sq.Ft.) (MmAnch) Elevation . <br /> L'07, <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Exacting <br /> Tanks Tanks <br /> Septic or Holdingins; 10 <br /> Doslnt Chamber 0 6 <br /> VII. Responsibility Statement- 1,the undo igned,assume responsibility for installation of the POWLS shown on the attached plans. <br /> Plumber's Name(Print) Plum 's Sia PRS Number Business Phone Number <br /> --� r a5 3��� �rSS�to ��r�► <br /> Plumber's Address(Street,City,Stam,Zip Code) <br /> OIC5w16K k)�_ `� <br /> 1. Count /De artment Use Only <br /> pproved ❑ Disapproved <br /> Sanitary Permit Fee(includes Groundwater Date Issued Ism' Agwt Signature(No Stamps) <br /> Sur rge Fee) ,M <br /> ❑ Owner Given Initial Adverze �. <br /> Determhtation ��/WWY <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plant(to the County only)for the rynem on paper not cess than 3112 x 11 inches to size <br /> SBD-6398 (R- 05/01) <br />