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Safety and Buddmgs D1viston counrj <br /> Va an W. Washington Ave..P.O.Box 7162 ,C�ea/'N <br /> visconsin 201 WG Madison,WI 53707-7162 Site Address f Y <br /> Department of Commerce /1 J2 q <br /> Sanitary Permit Application Sanitary PZer/mit Number / J <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide f �9(�/ I� v" <br /> may be used for second purposes PrivacyLaw,sl5.04(1)(m ❑ Check i Revision a <br /> I. Application Information-Please Print All Information State P I.D.Number C� <br /> Property Owner's Name Parcel Number <br /> Pioberty Owner's Mailing Address /�/, //�",,-. Property Location OV,t ,(,OT -a- <br /> 1 -31Y <br /> / 3 1/ e_ �� C I l COK 0 e� -A tA;S-0� T t<16 N.R�� <br /> City,Sta/tt J 'p Code / Phone Number Lot Number/ Black Number <br /> 1, I 6/�7`( -)66 3!U' iguhdiyision Name CSM Numbe <br /> s w- 7 v a �d <br /> IT'.Type of Building(cheek all that apply) --7�y ❑City _ <br /> ,All or 2 Family Dwelling-Number of Bedrooms of ❑Viinge _ <br /> ❑Public/Commercial-Describe UseijEtnwitship S c o <br /> ❑State Owned Nearest Road <br /> CO_ G <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B if a plicable) <br /> TB- O <br /> .or' For County use <br /> 2 7o�aceplacement System 3 ❑ Replacement of 6 ❑ Addition[o( Tank Onl Existin S stem <br /> if Sanitary Permit Previously issued Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non—Pressurized In-Ground 2111 Mound 47❑ Sand Filter So❑ Consimcted 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.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Raw(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sieel Fiber pi; ;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic ar Noldmit Tank ;a <br /> Dosing Chamber J <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached&,tss. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> I. Count /De artment Use Only <br /> pproved ❑ Disspproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin Agent Signature(No Sno ps) <br /> Surcharge Fee) /� -ma;^ <br /> ❑ Owner Given Initial Adverse 4h3�+ e � txM , <br /> -J Determination `Ir <br /> IX. Conditions of ApprovaVReasons for Disapproval <br /> Attach complete plats(lo the County only)for the system an paper not less than 8112%11 inches in ase <br /> S13D-6398 (R. 05/01) <br />