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fety <br /> I `� W. <br /> Was and Buildings Division Courry <br /> 1 ` � 20 W. Washington Ave., P.O. Boz 7163 (3ut.„�yc.f. <br /> �seonsin Madison, Wl 53707 -7162 Sire Address <br /> Department of Commerce X7,5-Il Ston <br /> c Rd <br /> Sanitary Permit Application _- Saniwry Permit Humber--- <br /> in accord with Comm 83.21, Wis" Adm. Code,personal information you provide "/ ` <br /> ma be used for seconda ou ses Privacy Law, s i.04(])j m) ❑ Check if Revision /�,� <br /> I. Application Information -Please Print All Information <br /> %I •_J�- <br /> Property Owner's Name Swte PIanI.D. Number(A -�-(- <br /> Parcel Number <br /> ProperOdd - 432-5- 63000 <br /> Property Owner's Mailing Address <br /> Property Location <br /> City,State 1A 'A:S 35 T 40 N, R I E <br /> Zip Code Phone Number Lot Number <br /> Block Number <br /> Luc y5-feel, <br /> fftr ur Subdivision dame CSM,Number <br /> 548'9,3 his-8'66-838�t <br /> II. Type of Building(check all that apply) <br /> H I or 2 Family Dwelling-Number of Bedrooms 04 ElCrry <br /> ❑ Pubiic.'Connnemal -Describe Use ❑village <br /> ❑State Owned ud`rownship 6/q ik/p,„d <br /> Nearest Road '— <br /> ill. Type of Permit: (Check only one box on line A (numbering scheme for internal Lase). Complete line B if applicable) <br /> A. r, <br /> ! Naw 2�j Replacement System 3 Repiaccment of 6 i� Addition to I For County use <br /> Svstem Tank Only <br /> ExistingSystem <br /> B. ❑ Check if Saniary Permit Previously Issued Permit Number Date Issued <br /> IV.�T/ype of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44.cy Non for <br /> In-Ground 2111 Mound <br /> 47 11 Sand Filter 50 G Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 El Holding Tank 48(] Single Pass SI ❑Drip Linc <br /> 45 11 At-Grade 46 C Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area <br /> P Soil Application Percolation Rate System Elevation Final Grads <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (3,lin.iinch) <br /> Elavatia❑ <br /> Sao ti A9 �i3dL . 7 <br /> VI. Tank Info Capacity in Total Number <br /> Gallons Manufacturer " Prefab Site Steel Fiber <br /> Gallons of Tanks Plastic <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> Scptic or Holding Tank 7SV <br /> Iso _ <br /> Dosing Chamber Sdig . t, <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW"fS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Siitnature <br /> MP/MPRS Numher Business Phone Number <br /> �ffHa2D �r/s /�. �/ 2zS$sl 7�S= g66- gfS7 <br /> lumber's Address(Street,City,State, Zip'Code) <br /> 27 7 4oo /'w S X48 3 <br /> VIII. Count /De artment Use 1 <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agen i Lure(N mps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> i <br /> AUS - 9 <br /> Attach complete plana(to[he County only)for the system on paper no s I/�i <br /> in 3 <br /> SBD-6398 (R. 06/01) zo I G <br />