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Wisconsin201 W. WashingtonAve.,P.O. Box 7162 y SrAor <br /> Madison,WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application sanitary Permit Number IJ <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide / <br /> ma be used for saopurposes Priv Law,515. 1)m) ❑ Check if Revision (�3���u_ O <br /> I. Application Information-Please Print All Information State Plan I.D.Number T ^n <br /> Property Owner's Name 1J�1 <br /> Parcel Number <br /> l�'iarra VA-4 110u 0..0- ►3dS_ oQ ypQ I <br /> Property Owner's Mailing Address <br /> Property Lot:aation <br /> /S'3/9 -57f�wAri" GI1. / tt/ ' <br /> City,State 'k u:S /Ss T yD N.R /6 E <br /> Zip Code Phone Number Lot Number—q Block Number <br /> Subdivision Ntmu CSM Number <br /> Inlnne fon Ire M N. sS3y5- 1060 Va � <br /> II.Type of Building(check all that apply) <br /> ®'1 or 2 Family Dwelling—Number of Bedrooms ❑City <br /> ❑Public/Commercial—Describe Use <br /> ❑Village <br /> ❑State Owned hip 04 E/ati� <br /> Nearest Road // n Q 0 <br /> Fe+eh't S tea I,dl• I <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> P''F New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> m Tank Ont E t System <br /> B. <br /> heck if Sanitary Permit Previously Issued Permit Number Dare Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Z Non—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.D' ersaWMMeatment Area Information: <br /> i <br /> Design Flow7(g Dispersal Area Dispersal Area Soil Application Percolation Rate System11 Elevation Final Grade <br /> Required Proposed Rare(Gals./Days/Sq.FL) (Min./Inch) Elevation <br /> Sao 600 yd .s- 91 <br /> VI.Tank Info Capacity in Total Number I Manufacturer Prefab Site I Steel Fiber I Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Exu=4 <br /> Tanks I Tanks <br /> Sepuc or Holding Tank /000 <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 /> � v �s 2zS$ 866- 4157 <br /> [umber's Address(Street,City,=C,Zip Code) <br /> 277 too j4w 35 <br /> I. Court /De artment UseOfilv <br /> proved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing at 'gnature(No ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse 4 aGD,0D / <br /> Determination / <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system an paper not leu than 81/2 x 11 Inches Ice size <br /> SBD-6398 (R. 05101) <br />