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Wisconsin ,,,Madison, <br /> WI 53 07 - Box 7)62 1 <br /> bfadison, WI 53707 -7162 <br /> Department of Commerce S`� <br /> Sanitary Permit Application I sammzy Pcrtmt Number <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide <br /> may be used for sect, 3Yj 3/b <br /> nes Privacy Law,s15. t)ml � ❑ Check if Revision <br /> I. Application Information-Please Print All Information <br /> Sure Plan I.D. Number �] <br /> Property Owner's Name IW^ <br /> Parcel Num(xr <br /> ire LarSo Dab- ��S -��-7QJ <br /> -f <br /> Propel/rye Owner's Mailing Address <br /> q7-?O 0 f-t e v [�C Property LocadonOV`6 w j <br /> City.Sate Zip CadePhone Number Lot Nu 1inber I S g T �0N,A /2{ <br /> lock N r <br /> Sbf be <br /> White sem- MY/ SS l/ tbS/- QA /.l 8'g Subdivision Name Numr <br /> II.Type of Building(check all that apply) <br /> gr f or 2 Family Dwelling-Number of Bedrooms 3 Cory <br /> ❑Public/Commercial-Describe Use ❑Village <br /> ❑Stare Owned 2ro"'mlop 5407,70 <br /> NeaxCar Road a Q <br /> III.Type of Permit: (Check only one box om line A(numbering L On z /?a(. <br /> ring scheme for internal use). Complete line B if applitvble) <br /> A. <br /> 1 J$ New 2 ❑ Rephtcearem System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> stem l.� <br /> B. ❑ Cheek if Sanitary Permit Previously Issued Petra stem Ntrttrber Date Issued <br /> IV.Type of Permit: (Check all that appiy)(numbering scheme is for interval use) <br /> 44 R Non-Pressurized In-Ground 2111 Mound 47❑Sand Filter 50❑ Constructed Wedand <br /> 22❑ Pressurized in-Ground 41 ❑ Holding Tank 48❑Single Pass <br /> 510Drip Line <br /> 45❑ AtZmds 46❑Aerobic Tmeamment Unit 49❑Reeireula. 30❑Other <br /> V.D' tment Area Information- <br /> Design Flow(gpd) Dispersal Area D' <br /> ReTiired Ioprsalosed Area Soil APPliouoa Percolation Rate System Elevation Final Grade <br /> Proposed Ram(GalsJDays/Sq.FL) (Min./Inch) Elevation <br /> i <br /> LlS`O 6 y3 6 ye 7 � 93. 6 9' <br /> VI.Tank Info capacity in Total Number Manufacnmrer prefab Sim Steel Fiber <br /> Gallons Gallons of Tanks Concrete Constructtd I plastic <br /> New Glass <br /> Tanks Tanks <br /> Septic or Holding Tank /600 - lDOO .2 <br /> Dosing Chamber >< <br /> VII.Responsibility Statement- I,the undersigned,assume responcrlrility for installation of the POWTS shown on the attachedplansPlumber's Name(Prim) Plumber's Signature MP/z;Z— <br /> Strect, <br /> Business Phone Number <br /> e-t�F Vp ,Js 2 71S lumber's Address( City,State,Zip code) <br /> 27 7 (o o 14w35 r 16g <br /> 1 , 2�4$ 3 <br /> vIII. our /De artment useUn <br /> Pe ujit i <br /> Approved ❑ Disapproved Sanitary Fee) Fee(includes Groundwater Date Issued issuing nature(N mcs) <br /> ❑ Owner Given Us=e �2 /� '\, <br /> Determination �C, t;�b <br /> IX. Conditions of Approval/Rewons for Disapproval <br /> I <br /> i <br /> Attach complete plans(to the Counq ody)for tae system m paper not less than 812 s 11 laches is nose <br /> SBD-6398 (R. 05/01) <br />