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Safety and Buildings Division County 17 ' <br /> 201 W. Washington Ave.,P.O.Box 7162 (- e <br /> 4seonsin Madison,WI 53707-7162 Site Address <br /> De artment of Commerce ,. G,1eQy�sl( 2r� <br /> Sanitary Permit Application Sanitary Permit Number, / <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide � 1 f v - L..f 3 r70 7 <br /> may be used for secondarypurposes PrivacyLaw,s15. 1 m Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number d <br /> er v�u 012 In 01 -S700 <br /> Property Owner's Mailing Address ` Property Location2 7 ✓i e '_'A 1 'A:S 26 T //() N.R /r <br /> E6 D <br /> City,State Zip Code Phone Number Lot Nqnber Block Number <br /> Subdivision Name CSM Number <br /> W 5 � w,- y�93 �7�D)X66- B?36 C��R Sk n QcreS <br /> II.Type of Building(check all that apply) ❑Ciry <br /> 2 1 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> EJ //� <br /> Public/Commercial-Describe Use 1�'I'ownship TgeK5 <br /> ❑State Owned Nearest Road <br /> dear' S44 <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 CY New 2 ❑ Replacement System 3 ❑ Replacement of 6 0 Addition to For County use <br /> System I Only Exis' S sum <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 rise) <br /> 44 'Non-Pressurized In-Ground 21❑ Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22 El 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 Soil Application Percolation Rate System Elevation Final Grade <br /> 1Required Proposed Rate(Gals./Da s/S4.Ft.) (Min./Inch <br /> ) Elevation <br /> 119-e�5 <br /> by3 6`!,g . 7 — Wd 6 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> qNewExistin; <br /> anks <br /> Septic or Holding Tank _ I�O Q <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assurne 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 /> c*V,V -7 S$S 1 15866- 4157 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z7 7 (o 0 low 35 LAB , _54-0613 <br /> VIII. County/De artment Use Oftly <br /> Approved ❑ Disapproved Sarutary Permit Fee(includes Groundwater Date Issued Is gent Signature o Stamps) <br /> Surcharge Fee) (� <br /> ❑ Owner Given Initial Adverse O o r O( <br /> Determination V` <br /> IX. Conditions of ApprovaUReasons for Disapproval <br /> Attach wmplete 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 />