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E1, <br /> Safety and Buildings Division County -Jl <br /> 201 W. Washington Ave.,P. . ox 7162 Ur/Ve/ _ _ <br /> ` ,Loons n Madison, WI 53 -7162 r� Si Address <br /> Department of Commerce___j �(� <br /> Sanitary Permit Applie t1U S�tarY Permit Number � <br /> In accord with Comm 83.21,Wis.Adm. Code,personal infomtatton you provide ❑ Check if Revisio � �0 <br /> may be used for secondary purposes Privacy Law, <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> ov <br /> e-17- ��b 3 / 6 `ham <br /> Property Owner's Ma ing Address Property Location y <br /> Uta <br /> Aj(A/%-5 SA;S16 T �ON. R1/ E ' <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> 91 <br /> h,Nen W; 5Sy72 7/5 <br /> R.Type of Building(check all that apply) ❑City <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑ Public/Commercial-Describe Use Township LI/U[Ddy <br /> ❑ State Owned Nearest Road <br /> 4! r t <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 f New 2 ❑ Replacement System 3 ElReplacemen[of 6 ❑ Addition to <br /> System Tank Only Existing System <br /> B. ❑ Permit Number Date Issued <br /> Check if Sanitary Permit Previously Issued i <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,K Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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 Soft Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> �T6 05 q7Z gf z <br /> VI.Tank Info Capacity in Total Number I Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks t� <br /> Septic or Holding Tank /.end r- t <br /> Dosing Chamber Utll <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> �#R�ZD ir/S 22S$S 1 715- S66- �S7 <br /> lumber's Address(S[reet,Ciry,State,Zip Code) <br /> 27 7 (o o f 4w 315 <br /> Vill. Count /De artment Use 1 <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> 7�Approved ❑ Disapproved Surcharge Fee) .7�, O <br /> ❑ Owner Given Initial Adverse p�,�, O� I�-'' [� J��l`Jtt-rte Mai-,`� <br /> Determination — — <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> I <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 05101) <br />