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Safety and Butlamgs Division t.ounty <br /> 201 W. Washington Ave., P.O. Box 7162 (3u11>� <br /> W r <br /> isconsin Madison, WI 53707 -7162 Site Address <br /> Department of Commerce 9559 //Qin s R%Q <br /> Sanitary Permit Number l.N <br /> Sanitary Permit Application Sanqq �y <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision �-7$ 5 S O V I <br /> ' <br /> ma be used for Seco purposes PrivacyLaw. 15.04 I m <br /> 1. Application Information-Please Print All Information State Plan I.D. Number <br /> �5 <br /> Property Owner's Name Parcel Number <br /> /38.6 0d6' '//// o/SOO <br /> Property Owner's Mailing Address Property Location <br /> „�77,� w <br /> /SS /�ai/a3 ". SW's f�u;S // T 4D N,R q/ <br /> City,Sate Zip Code Phone Number List Number ' Bleck Number <br /> Subdivision Name CSM Numbe <br /> ✓` oaner L4/ 0 esm V g los <br /> IL Type of Building(check all that apply) ❑City _ <br /> R'l or 2 Family Dwelling-Number of Bedrooms Z{ ❑Village <br /> ❑Public/Commercial-Describe Use ®'township .1[077`- — <br /> ❑Sure Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicabh•) <br /> A' I ❑ New 2,0 Replacement System 3 ❑ Replacement of 6 ❑ Addition m For County we <br /> S stem Tank Ont Existio system.. <br /> B. ❑ Check 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,V Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wedand <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Gude 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersal/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 /> 600 !J e0 N-OO -5— 90./a-o87..2 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site S,ceI Fiber PI. itic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Eautin9 - <br /> T. t `/ <br /> 5rytic ar Holding Tank 4d 0 Z Sr4's w Ik <br /> Dating Chamber <br /> VU. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plc,ns. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Pbon:Number <br /> R/c;/e- /F 1 7/r-s-4,6 <br /> Plumber's Address(Street,City,Sure,Zip Code) <br /> X7760 3.5— w.e6syler � w< - s�893 <br /> !7M <br /> ent Use Only <br /> pproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing or S more(N I'ps) <br /> Surcharge Fee) <br /> er Given Initial Adversenation <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Atuch complete plana(to the County only)for the system on paper not Iw than ally x I1 inch"in size <br /> SBD-6398 (R. 05/01) <br />