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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> NVisconsin Madison, WI 53707 -7162 Site Ad ess <br /> department of Commerce tNZ� <br /> Sanitary Permit Number <br /> Sanitary Permit Application <br /> In accord with Comm 83 11.Wis.Adm.Code,personal information you provide ❑ Check if Revision/[,j/�-3 <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) <br /> I. Application Information-Please Print All information State Plan I.D. Number / <br /> Property Owner's Name Parcel Number (� j <br /> omw>✓ OaS- Ia�F-o3 <br /> Property Owner's Mailiingg Address f Property Location A <br /> 17CO - / -10 '4 S4:S �4T 40N, R J4 <br /> City,State Zip Code Phone Number Lot Nyjttber Block Number <br /> !� 1 <br /> po R W Subdivision Name CSM Number <br /> H.Type of Building(check all that apply) ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village <br /> ❑ Public/Commercial-Describe UseS <br /> �'ownship WM <br /> ❑State Owned Nearest Road <br /> CoC/ Rd G <br /> III. Type of Permit: (Check only one box online A (numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 ❑ New 2 ❑ Replacement System 3�Replacement of 6 ❑ Addition to <br /> S stem Tank Only Existin System <br /> B. Check if Sanitary Permit Previously Issued Permit Number 3S a Date IssLted�/ <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) ��//VV1l <br /> 44 ❑ Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wedand <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(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed <br /> Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> VI.Tattle 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 /> Septic or Holding Tank I 2 Z 1 <br /> Dosing Chamber Y) <br /> e�V <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number i <br /> c�It}�zp irls - 2ZS$S 7/S- $66- q-IS? <br /> Plumber's Address(Street,Ciry,State, Zip Code) <br /> 27 7 &0 }4w�j Ug6 , <br /> VIII. Count /Department Use 1 <br /> Sanitary "Fee1mcludes Gro1-m—d,arer Date IssuedIssu ng'Age Signature(N ta ps) <br /> Disapproved Surchar / ,�'\ /, <br /> ❑ Owner Given Initial Adverse <br /> Determination - —{ <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plata(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 />