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Safety and Buildings Division Count) <br /> 20? W. Washington Ave., P.O. Box 7162 l�L�r � <br /> h� <br /> Wisconsin Madison, W1 53707 -7162 Site Address <br /> Department of Commerce __ 98N0 SArtd Lk ?�__ <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Cortes 83.21,Wis. Adm. Code,personal information you provide ❑ -�--5� lo1ll/ 1- <br /> Check if Revision <br /> may be used for secondary puMoses Privacy Law, i.04(U(m) <br /> L Application Information -Please Print All Information Sate Plan I.D. Number <br /> . a 1a <br /> Property Owner's Name Parcel Number <br /> GGtuolc L °acct 01J.- 4044-=d3r3oo <br /> Property Owner's Mailing Address Property Location G-ov4--,Lv <br /> 5"t40 CG✓(Son R41. k H;S}S T #0N,RfS E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSN1 Number <br /> _5AveeV/ew MA4 <br /> R.Type of Building(check all that apply) ❑City <br /> �i l or 2 Family Dwelling-Number of Bedrooms [Village <br /> ❑ Public.'Commercial-Describe Use IRTownship ,,10.okse#I <br /> ❑ State Owned Nearest Road <br /> .5r <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A r� For County use <br /> 1 iJ New 2 q Replacement System 3 ❑ Repiaczment�f 6 ❑ Addition to <br /> System I Tank Only Existuot <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 r IJon-Pressurized In-Ground 21❑ Mound 47❑ Sand Filter 50❑ 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(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rare System Elevation Final Grade <br /> Required Proposed Rate(Gals./DaysiSq.Ft.) (Mia./inch) Elevation <br /> MDQ 8�7. 864 . 7 <br /> VI.Tank Info Capacity in Total Number Manufacn rr Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 4M / <br /> It- <br /> Dasing Chamber 7<0 7SQ <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plaits. <br /> Plumber's Name(Print) Plumber's Signature MPJMPRS Number <br /> Business Phone Number <br /> c ?oev »✓s �z� ��, .�- Z2-5 S I is- $66- 4157 <br /> lumber's Address(Street,City,State,Zip Code) <br /> �w <br /> V I. Count /De artment Use 1 <br /> Sanitary Permit Fee(includes Groundwater =IssuedIssuing en;L ,,n;aruro mpsl <br /> Approved ❑ Disapproved Surcharge Fee)❑ Owner Given Initial Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in she <br /> SBD-6398 (R. 05/01) <br />