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201 W.Washington Ave.,P.O.Boz46' <br /> Wisconsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number 3 z4 <br /> In accord with Coruna 83.21,Win.Adm.Code,personal information you provide <br /> tna be used for secondaryPriv Law.s15. 1)(m) C3 Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name <br /> Parcel Number <br /> ( mss Widde✓ G0 q3 -�>' tot-) I <br /> Property Owner's Mailing Addmss ) ( �) _ Pro <br /> /I � ' 7 <br /> r4UI <br /> li�. /V',�. . Property Location <br /> City.State , r •ylO % 54;S /6 T 40 N.R �I <br /> M l /V Zip Code / Phone <br /> Number Lot N tuber Black Number <br /> PS � Subdivision Name CSM Number <br /> 24inbaw Lk. <br /> II.Type of Building(check all that apply) <br /> ❑City <br /> N 1 or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned grownship 0,01and <br /> Neatest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Com tete line B pp'if a h�b e k <br /> P ) <br /> 2 11 Replacement Sysmm 3 Replacement of Aditoo For County use <br /> stem Tank On'-- <br /> if <br /> n'if Sanitary Permit Previously Issued Permit Number Date Issued <br /> W.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 JR 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 Lina <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/Inch) <br /> �l 7 LAPP-er `>5.1• Elevation c& <br /> 300 yJ,91 7 3 JL • ( 1' loW'Er 44.7 <br /> 97 <br /> 7 I <br /> VI.Tank Info Ca in-- <br /> Tom] Number <br /> Manufacturer Prefab Site I Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existiag <br /> Tanks Tanks <br /> Septic or Holding Tank goo _ 4p / <br /> s/caw <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached pians. <br /> Plumber's Name(Print) Plumber's SignatureMP/MPRS Number Business Phone Number <br /> zzsSs gra- 44s7 <br /> Plumber's Address(Street.City.State,Zip Code) <br /> 277 (oo <br /> I <br /> I. County/De artment Use Ofily <br /> t,qA <br /> pproved Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin nt Signa o Stamps) <br /> Surcharge Feer <br /> ❑ Owner Given Initial Adverse <br /> Determination cc <br /> t(J <br /> IX. Conditions of ApprovaUReasons for Disapproval <br /> 41 p4orkAZO4 <br /> e� O <br /> Attach complete plana(to the County only)for the system on paper not len TS—In x-ii lochs m aiae <br /> SBD-6398 (R. 05101) ��ti/41 (�N <br />