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Safety and Buildings Division Cour. <br /> 201 WW. Washington Ave.,P.O.Box 7162 4,73,4.1 ... pv <br /> ` isconsin Madison,WI 53707-7162 Site Addresst <br /> • Department of CommerceSanitary Permit Number <br /> ki <br /> Sanitary Permit Application ,2s-gC) if 0 f 7© <br /> In accord with Cotrim 83.21,Wis.Adm•Code.personal information you provide ❑ heck if Rev sion <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) • <br /> I. Application Information-Please Print All Information State Plan I.D.Number/0 q a e/ <br /> Parcel2 A.. <br /> lNumber 7•.!1 <br /> Property Owner's Name � / <br /> L) ) /3G/7 e ' 0-2r y/r2f/ <br /> c C / ICC) <br /> % <br /> Pq <br /> Property Location <br /> Property Owner's 'ing Address / / �/ Pj....,i/ �� 7Zip Code Phone Number Lot Number Block NumbergrIblftwtsietrrNitin <br /> City,State <br /> e CSM Number <br /> Z---LiCk . --- 53'0153 2-2-3.7C I/ ,3--- /0 ,V-70--1-A.2/ <br /> H.Type of Building(check all that apply) ❑Ciry <br /> or 2 Family Dwelling-Number of Bedrooms / ❑Village <br /> ❑Public/Commercial-Describe Use Aownship ..SG O7171- <br /> Nearest Road <br /> 0 State Owned o e / 6- <br /> III. <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' _Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> For County use <br /> iis,:m l Tank Only Existing System /� <br /> B. heck if Sanitary Permit Previously Issued Nhiatilk. ed <br /> 9�/ 314 6 /n <br /> IV.Type of Permit: (Check all that apply)(numberin scheme is for internal use)f1 <br /> 44 El Non-Pressurized In-Ground 2t ,Mound 47 0 Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground Holding <br /> 41❑ Tank 48 0 Single Pass 51 0 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 /> .3-0 / o /S"Q /Manufacntrer mo / ,. AXank Info Capacity in Total Number Prefab Site Steel Fiber Plastic <br /> VI.T <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New ' Existing <br /> Tanks Tanks _ <br /> Septic or Holding Tank ��5-a / 75 $ ^ ) <br /> Dosing Chamber 7S-0 175-0 JJ`G� <br /> VU.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plum/ber's Name(Print) / 4 - 44 2 /q 7 .,.f/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> "do,e ,5-/y S /i-.e J 5 /LS 7.7._ <br /> VIII.County/Department Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing eat Signa;A No Stamps) <br /> !/ ..proved 0 Disapproved Surcharge Fee / ( /tlJ�� <br /> I ❑ Owner Given Initial Adverse .r� �D sx71 C �� l iht <br /> Determination (/1". W .c <br /> IX.Conditions of Approval/Reasons for Disapproval rte <br /> „.„.c...--A x et ctit <br /> 1 Bei6,0 Sithillti (.5/5.1-rm. Occ.c.,...ta.,47,cy (....). <br /> 5' l ( k onl!y) system notAttachtarh complete plans(to the count, for the on paperleaf than 81/ x 11 Inches In size <br /> Attach <br /> SBD-6398 (R. 05/01) <br />