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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 UWd <br /> isE:!k! n Madison,WI 53707 -7162 Site Address <br /> Department ce g3o ��1Z° <br /> Sanitary Permit Number <br /> Sanitary Permit Application 445 (o76 <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> maybe used for secondary purposes Privacy Law,sl5. 1 m <br /> I. Application Information-Please Print All Informatio n D,t� 3 a Os State Plan I.D.Number <br /> Property Owner's Name (, 0 Parcel Number <br /> RuCIF_ 'KA$MN 5+E14 b 00- 1tz-al-tco W <br /> Property Owner's Mailing Address Property Location <br /> 557 EAS EAki 'DQ • ss u:S 13 T IV N,R V <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> ,�,� � o N. 45432 137.4.2q -3GSq U di ision Name CSM Number <br /> Pf-III.Type of Budding(check aU that apply) ❑City <br /> X,or 2 Family Dwelling-Number of Bedrooms ❑village <br /> ❑ Public/Commercial-Describe Use ownship <br /> ❑ State Owned Nearest Road <br /> e-t`N1 . <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1t New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank Only Existing System <br /> Permit Number Date Issued <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> )V.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Non-Pressurized In-Ground 21%Mound 47[1Sand Filter 50 11 Constructed Wetland <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.Dispersal/Treatment Area Information: <br /> Design Flow(SO) Dispersal AreajDispe Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 450 4�o - q a 7 .1 qq- <br /> VI.Tank Info Capacity inNumberManufacturer Prefab Site Steel Fiber plastic <br /> Gallonsof Tanks Concrete Constructed Glass <br /> New ExistiTanks Tanks <br /> Septic or tinkling Tank 1000 <br /> Dosing Chamber t <br /> VII. Responsibility Statement- I,the undersigned,assume 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 /> r/S 22-58 S 1 71�= �fo6- �S? <br /> lumber's Address(Street.City,State,Zip Code) <br /> 2.7 7 fp o iffw 35 . -54$13 <br /> VIII.Coun /De artment Use Unt <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing t ture tamps) <br /> Approved ❑ Disapproved Surcharge Fee) AIA,) <br /> ❑ Owner Given Initial Adverse `� 'Je;/7 f 8V �3 <br /> Determination ^✓✓vv <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach omplete plana(to the County only)for the"emm paper not less than 8112x 11 Inches in size o <br /> SBD-6398 (R. 05101) f� ��� � <br />