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Safety and Buildings Division County <br /> �,,, 201 W. Washington Ave., P.O. Box 7162 Moe. C a -031 <br /> ISCOfSI n Madison, WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary ❑ Check if Revision , <br /> y ndary 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 <br /> CxYcicm i z uwe9 022-b9Ce5-24 -gS7O=o <br /> Property Owner's Mailing Address Property Location <br /> 1219 VigierSt• SE IA SW56:S24 T Gj N,RS E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> 1 <br /> Subdivision Name CSM Number <br /> LCX,It l L\11 5-3r3;5 SSZ- '7232 t'1::= <br /> II.Type of Building(check all that apply) <br /> OCity <br /> V1 or 2 Family Dwelling-Number of Bedrooms — ❑Village <br /> ❑Public/Commercial-Describe Use p Dane, <br /> -- O`fowrshi <br /> ❑State Owned Nearest ad <br /> _ St-C e41 A. Psoctcl <br /> M.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complet%line B if app),able) <br /> A. 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to Fur County c f <br /> System Tank Only Existing System <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number / Dal/Issued' <br /> N j' -. / <br /> IV. pe of Permit: (Check all that apply)(numbering scheme is for internal use) ' `�_ . <br /> 44 fiA Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Welland <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 de <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Mir../Inch) t ,o1 i Elevation <br /> (.49(30 y . 101.et <br /> L i�C?-ct•L 1 12 ci.2- .`-r — �I ,D 101.0' <br /> VI.Tank 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 Lose) lt.o '7 t M 4 Pi <br /> Dosing Chamber 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 /> AvrAre w W•WA Vt(lL i Z Al'A w•�-)".." MPlz . xtes 6-3i-St C>,3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 43c)-7 Cfi1. Hwy. 14- WCAU11at(.f, tr.11 55A"7 <br /> VIII. County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse ...47 -oZ kG <br /> Determination -co <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 size <br /> (,T)T /nnn fr. n.-re". <br />