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7♦ ]. �{����� „ Madison, W(jggy-�7 162 <br /> Y�( o Site Address <br /> Decartment of Commerce P(/1E n �r fl ef f <br /> 1 Sanitary Permit Application t`umber <br /> In accord with Comm 33.21, vis. Adm. Code, personal information you provide / /� <br /> may be used for second ourooses Prvac+Law,s 5.04(1)(ml ❑ Check if Revision ! �� 3v 7 <br /> I• application Information-Please Print All Information _//// <br /> /�� State Plan I.D. Number <br /> Property Owner's Name <br /> ParDellf— <br /> cel Numcer <br /> � san l�s'-vs' -dap 1 <br /> Property Owner's Mailing Address <br /> i Property Location <br /> MV!4 S W``: S J1 T y 0 N.R 11{ E i <br /> City,State Zip Code Phone Number <br /> Lot Number Brock Number I <br /> G•ov1'-Got 1. j <br /> S Subdiv 'on Name 1 Number i <br /> w h•e� Zt/,r S'f Aso i <br /> II.Type of Building(check all that apply) <br /> 1 or 2 Family g Dwellin -Number of Bedrooms o� I ❑City <br /> ❑ Public.'Commercial-Describe Use []Village <br /> State Owned g'I•owmhio eD 1Ff- i <br /> Nea--est Road a <br /> M.Type of Permit: (Check only one boa on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition o <br /> For County use <br /> 1. <br /> System Tank Oniv Ezistin¢ Svstem <br /> Permit Number <br /> B• : Check if Sanitary Permit Previously Issued � Date issued <br /> I <br /> I <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,�1 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter c <br /> I <br /> 0❑ Constructed Wetland j <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.DisoersaUTreatment Area Information: <br /> Design'rlow i <br /> g (gpd) Dispersal Area Dispersal Area Sod Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals.,Days/Sq.Ft.) (Min./Inch) <br /> 36 p 94' 4 F1e�ti°s <br /> 6 �s:y <br /> I <br /> VI. Tank Info Capacity in I Total Number I i Prefab Site Steel i Fiber i plastic <br /> I Manufacture- <br /> Gallons Gallons of Tanks I Concrete Cotrsavc zed <br /> i Glass ,j New Frinly <br /> I Tanks Tanks I I I <br /> Septic or Holding Tank 800 goo <br /> Dosing Chamber I I I I I <br /> I I <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the PONVTS shown on the attached plans. t Plumber's Name(Print) I Plumber's Signature MP/MPRS Number <br /> Business Pbone Number <br /> �71 �7 <br /> I I <br /> Ciry I <br /> Plumber's Address(Street, ,State, ZipCode) <br /> 27-7 (o 0 4W �S £g <br /> �4g 3 <br /> VIII CountvlDe artment Use lv <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued 1 Issuing A tgnature(, mph) <br /> Surcharge Fee) i <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> U. Conditions of ApprovaL/Reasons for Disapproval ` <br /> JUL 2 S 2003 <br /> BURNE TT CnUN-ry i <br /> Attach complete pL-uu(to the County only)for the system on paper not les inches in size <br /> SBD-6398 (R. 05101) <br />