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Safety and Buildings utvlston t-ounty <br /> 201 W. Washington Ave., P.O. Box 7162 � g <br /> c.rn7'7`- <br /> 2 rseonsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce 1 9491 flansPm 1/c <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Colton 83.21,Wis.Adm.Code,personal information you provide ����(/ i vT be used for second purposes PrivacyLaw sl5. 1)(m ❑ Check if Revision <br /> ma , <br /> I. Application Information-Please Print All Information Sure Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> /Y1 j/eS n rse�t Off$- 9/DD- L Sd O <br /> Property Owner's Mailing Address Property Location <br /> s-a43 1/107cB.77" A/ S. u u:S 6 T W N.R <br /> City.State Zip Code Phone Number Lot Number Bleck Number <br /> Su ivision Name CSM Numbe <br /> Inp If /;7 N o -9a r 36 el LaKe 0 o5is_ <br /> II.Type of Building(check all that apply) Dory <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms o1f <br /> ❑Village _ <br /> ❑Public/Commercial-Describe Use f gTownship s!Q'7�� <br /> ❑Sure Owned Nea st Road <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for Internal use). Complete line B if applicable) <br /> A. 1 ❑ New 2/a Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tack Onl ExistingSystem <br /> B. ❑ Check if Sanitary Permit Previously Issued Pmmst Number Dale Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 CyNon-Pressurized In-Ground 210 Mound 47❑ Sand Filter 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. 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 /> 30 o yd 9 y3� • 7 � 9/.3 4s r <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site S eel Fiber PI; tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic of Holding Tade DO - ee e 2- <br /> -5;1--t Chamber <br /> VII. Responsibility Statement- I,the undersigned, assume responsibility for installation of the POWTS shown on the attached plc,tu. <br /> Plumber's Name(Print Plumber's Signature MP1/M1PRS Number Business Phon:Number <br /> R/G/L /mss ,�i n f f� <br /> Plumber's Address(Street,City.Sure,Zip Code) <br /> 3-T WedsfP� W -7 SYdy3 <br /> I. Count /De artment Use Only <br /> nDeterminsdon <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Sigtnmre(No Starps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> lq-S <br /> LX. Conditions of Approval/Reasons for Disapproval L_ l <br /> <L i 2005 <br /> 005 <br /> Attach complete plans Ito she County only)for the system on paper nm less than 31/2 s l l inches io;NING �' r <br /> SBD-6398 (R. 05/01) LV <br />