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xxigr <br /> and Buildings Division County <br /> 201 W. Washington Ave., P.O.Box 7162 <br /> isconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce I /tD <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> ❑ Check if Revision <br /> may be used for sew s PrivacyLaw, 15. 1Hm fF ,L 1 1 <br /> I. Application Information-Please Print All Information Sate PVA Number <br /> Property Owner's Name Panel Number <br /> AAZ'cs ��/h-/r� 4- ©6-Q — QO <br /> Property Owner's Mailing Address /� o �/// Property Location <br /> I ���- /t"I�C L �(/ Si ll:S T .R I� <br /> City,State Zip Code —Phone <br /> GNumber Lot Nu ber Hlock Number <br /> Subdivision Name CSM Number II.Type of Building(check all that apply) ❑City <br /> YI or 2 Family Dwelling-Number of Bedrooms <br /> ❑V81age <br /> ❑Public/Commcrcial-Describe Use ownshi <br /> ❑State Owned Nearest Road <br /> SC <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. iNew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S em Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dau Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 21Mound 47❑ Sand Filter 50 11 Constructed Wetland <br /> 22 C1 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.Dis ersaVTreatment Area Information <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Raw(Gals./Days/Sq.Ft.) (MinJInch) Elevation <br /> 4s0 415'0 ASO /,b leo, q2 /p;7, 2 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> r Nekling Tank Me <br /> n ham v n <br /> VII, Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum 's Name(Print) Plumbe 's ignature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,Stare,Zip Code) <br /> A LG <br /> "Conditiow <br /> ment Use Only <br /> approved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signature( tops) <br /> Surcharge Fee) n <br /> ner Given Initial Adverse <br /> ination <br /> provaUReasons for Disapproval <br /> Arsach completeplans(to the County only)for the system on paper not less than 81/2 s I1 inch"to size <br /> SBD-6398 (R. 05101) <br />