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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 e/ <br /> Madison,WI 53707-7162 Site Addres //,q, 9S �d�e <br /> isconsin � <br /> De artment of Commerce Sanitary Permit Number ��� <br /> Sanitary Permit Application <br /> hi accord with Comm 83.21,Wis.Adm.Code+personal information you provide ❑ Check if Revision <br /> maybe used for sero ses Privac LaW,s15. 1)(M Stan plan I.D.Number v) <br /> I. Application Information-Please Print All Information 1 <br /> Parcel Number SG p <br /> Property Owner's NameQ t O Y.2U / <br /> r � /s N,4/v Property Ucadon <br /> Property is Mailing Address <br /> y !4;S N,R <br /> g 1 T W le- 4e r/ ' Phone Number Lot Number Black NUMMI <br /> State zip Code <br /> / Subdivision Name CSM Number <br /> H.Type of Building(check all that apply) ❑City <br /> Number of Bedrooms ❑Village <br /> ,it,or 2 Family Dwelling- <br /> - ownship A/00 i''" <br /> ❑Public/Commercial-Describe Use Nearest Road <br /> ❑State Owned 1 f' <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> For County use <br /> A. 1 C3 New 2 XReplacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> Tank Onl Exis' S stem Date Issued <br /> S sum permit Number <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> 1V.Type of Permit: (Check all that apply)(numbering scheme is for internal use) 50 L3 Constructed Weiland 47❑ Sand Filter <br /> 44 11 Non-Pressurized In-Ground 51 Drip Line <br /> 41 ❑ Holding Tank 48[I Single Pass <br /> 22 El Pressurized In-Ground 30❑Other <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49[1 Recirculating <br /> V.Dis ersal/Treatment Area Information: percolation Rate System Elevation Final Grade <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Min./Inch) Elevation <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) <br /> .300 � o � 3ov /� 775' 953. 3 <br /> Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> VI.Tank Info Capacity in Concrete Constructed Glass <br /> Gallons Gallons of Tanks <br /> New Existing <br /> Tanks Tanks _/ <br /> Septic or Holding Tank 7S6 - G /' <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned'assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print)A Plumber's Signatu <br /> MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,zip Cade) <br /> VIII.Court /De artment Use Onl <br /> Sanitary Permit Fee(includes Groundwater Dau Issued Issuing A nt Si tar Stamps) <br /> IN Approved ❑ Disapproved Surcharge F ) / <br /> ❑ Owner Given Initial Adverse OO a <br /> Determination <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Attach complete pians(to the County only)for the system on paper not len thea 91/2 x 11 Inches to size <br /> SBD-6398 (R. 05/01) <br />