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Safety and Buildings Division County <br /> � 201 W. Washington Ave.,P.O.Box 7162 U <br /> iseonsin Madison,WI 53707 -7162 Site Address <br /> Department of Commerce / yye0,,PJF (� <br /> Sanitary Permit Application Sanitary Permit Number y <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15. I m ❑ Check if Revision <br /> I. Application Information-Please Print All Information7=� State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> lvfke 1 7 4-17-6 0) 800 <br /> Property Owner's Mailing_A`ddrr^ess Property Location n, '/ <br /> 3 C�/t Cl 4. !6 S4;S L6- T 17D N,R //( <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> 5�qBo/ 7/J 6 N. 7:0��,�'L 2 e�:se- 2/Op,lo <br /> II,Type of Building(check all that apply) en <br /> �./ ❑CityI or 2 Family Dwelling-Number of Bedrooms I ❑Village <br /> ❑ Public/Commercial-Describe Use <br /> ownship <br /> ❑State Owned Nearest Road n' c <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> FINe 2 V Replacement System 3 11Replacement of 6 ❑ Addition to For County use <br /> Tank Oni Exis' S stem <br /> B• if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 V Non-Pressurized In-Ground 20 mound 47❑ Sand Filter 50❑ Constructed Weiland <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 ASystem Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) 46.7- qS-4. Elevation <br /> 6� /200 /200 -- q 3-$ , R3 �'►M�n/ <br /> •8 CovEn <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site I Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holing Tank / /ZSO / ljtlS `� <br /> Dosing Chamber <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 /> 4*»oev wsI R. - zzs8 s 1 71.5- 866- 415-7 <br /> lumbei s Address(Street,City,State,Zip Code) <br /> 277 (00 4w 35 ua . 2�¢8 3 <br /> I. Count Department Use Oftly <br /> pproved ❑ Disapproved Sanitary Permit Fee(,'rp-cludes Groundwater Date Issued Issuin��geentt Signature(No Stamps) <br /> T � <br /> ❑ Owner Given Initial Adverse <br /> Surcharge Fee) VV• OU � i2 "`r" V' t�-�/ J � <br /> / <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete phuu(to the County only)for the system on paper not less than 91/2 x 11 Inches in size <br /> SBD-6398 (R. 05/01) <br /> mel <br />