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Safety and Buildings Division County <br /> iseonsin 201 W. Washington Ave.,P.O.Box 1162 <br /> Madison,WI 53707-7162 Site Adds ss <br /> Department of Commerce — <br /> Chi d 6 <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,persotnl information you provide i <br /> may be used for secondarypurposes PrivacyLaw,sl5. 1 m ElChe �isi,,P (1 l <br /> I. Application Inforrtradon-Please Print All Information ,/ State Plan I.D. Number <br /> Property Owner's Name <br /> Y. Parcel Number � i <br /> IC I/(r11 Off �� //7 <br /> PrOpErty Owner's Mailing AddressOZO 14 O1 <br /> yN����jn� Property Location <br /> S 0-5-Al t`.."` 4 R;S 4 T N,R /6 <br /> City,State �J'` M/► Zip Code Phone Number Lot Number <br /> 14PPt V/1W�, ' `/ - s���' ��z 1✓3 L�� Subdivision Name CSM Number <br /> II. ,Type of Building(check all that apply) <br /> or 2 Family Dwelling-Number of Bedrooms ❑City <br /> ❑village <br /> ❑ Public/Commercial-Describe Use P ` <br /> owns It <br /> State Owned /V <br /> ❑ <br /> Nearest Road <br /> (0- Rb <br /> III.Type of Permit: (Check only one box online A(numbering scheme for internal use). Complete line B if applicable) <br /> A. ..�off,r For County use <br /> !XJ'New 2 ❑ Replacement System 3 ❑ Replacement of I ❑ Addition to <br /> S stem Tank Ord Exis' S stem <br /> B• ❑ Check 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 /> 442dNon-Pressurized In-Ground 210 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 Rate System Elevation Final Grade <br /> Required Proposed Rare(Gals./Days/Sq.Ft.) (Min.lInch) q¢ 7 EI vation <br /> qDO qc �� s 71 ire. <br /> 3 $ 3 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber I Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tattles TaNcs <br /> Septic or Holding Tank <br /> J' <br /> Dosing Chamber <br /> i <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 /> j <br /> etFRaev d< <br /> L7 ZS$S 1 7 g66- 4157 <br /> Plumber's Address(Street.City.State,Zip Code) i <br /> 27 7 (o v 4w % A@ -5¢8 3 <br /> I. County/Department Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu' gent Signature(No Stamps) <br /> Surcharge Fe <br /> /r-��� <br /> ❑ Owner Given Initial Adverse <br /> Determination ,;W, " ✓ <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> I <br /> Attach complete plans(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 />