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Safety and Buildings Division Coin <br /> 701 W.Washington Ave.,P.O.Box 7162 VR ,L <br /> Ivisconsin Madison,WI 53707-7162 Site Address <br /> De artment of Commerce e <br /> Sanitary Permit Application Samar"Permit Number $ 9J <br /> in accord with Comm 83.21,Wis.Adm.Code.personal information you provide 3 / <br /> may be used for PrivacyLaw,s 15. 1 m Check ��10° <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> w/,? & v <br /> Property Owners MailingAddrin �. rry Location <br /> f �L- VV;S T 7/N,R <br /> Smm�j , Zip Code Phone Number Lot Number Block Number <br /> 0C�i�5�PiI M �M �� O/ 57o7 Subdivision Name CSM Number <br /> S5Y 621 9 a$5 fsiz <br /> II.Type of Building(check all that apply) <br /> ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms ❑V e <br /> ❑Pablic/Commercial-Describe Use <br /> 0 <br /> ❑Sete Owned Nearest Road <br /> Gd 4 :A' 3SD <br /> M.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. Ijig New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> wttern I I Tank Only ExistExistmg System <br /> B. I ❑ Check if Sanitary Permit Previously Issued Permit Number —7-Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 u Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50 13 Constructed Wetland <br /> 22/❑�Preswrvld In-Ground 41❑Holding Tanka 48❑ Single Pass 510Drip Line <br /> 45❑At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. eatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation F'mal Grade <br /> Requited Proposed Rate(Gals./Days/SgXQ (Min./Inch) Elevation <br /> iso �7S �7�6 112 7W, 0 9 g. <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> Ncw F't <br /> Tanks Tanks <br /> Holdioj Tank <br /> Dosiq Cmumber <br /> DV <br /> VII.Responsibility Statement- I,the tmdersignedr assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P s _ MPIMPRS Number Business Phone Number <br /> 41i 73 <br /> lumbo s Address(S Chy,sate. Code) <br /> Column /De artment Use Only <br /> f Appro,ved ❑ Disapproved Sanitary Permit F includes Groundwater Date Issued Issuing Agent Si re IN tamps <br /> D� Surcharge Fee) <br /> ❑ Owner Gives Initial Adverse <br /> Determination (O <br /> Ix.Conditions of Approval/Reasons for Disapproval / <br /> Attach tomPktg PAm(a the County only)for the system an paper not ten than 8112 x 11 Inches in rise <br />