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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> visconsin Madison,WI 53707-7162 Site Address / <br /> De artment of Commerce GAp' AIWA Q q376 �w <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 13 Check[k i <br /> may be used for secondarypurposes PrivacyLaw,sl5. 1 m evis[on <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> 3 go- U, <br /> Property Owner's Name t Parcel Number <br /> rt6 gmder`Jor-j 606Z-1-05 OI 92o c1 <br /> Property Owner's Mailing Address Property Local <br /> 16-6 _ V 2 �r <br /> 75 � 15(J �F� ti 'A;S3 T�t�Q N.R li / E <br /> City.State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> l 1fN rn� SSo 33 <br /> 11.Type of Building(check all that apply) []city <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 <br /> ❑Village <br /> ❑ Public/Commercial-Describe Use <br /> gI'owaship /%j <br /> ❑State Owned Nearest Road <br /> 1A <br /> -4k 4,96kflrh!2�5 <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if atplicable) <br /> A. 1 It New 2 [1Replacement System 3 ❑ Replacement of 6 11Addition to For County use <br /> stem Tank Only <br /> Existing System <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 /> 44 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized ht-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 SystemElevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (.Min./Inch) <br /> ry-CP gy,fj Elevation <br /> y5� 6113 6Kg . 7i <br /> 7 _ 70P 475- j <br /> l�o�kn QZ,S" eoIf&" �wS <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic <br /> Gallons Gallons of Tanks Concrete Constntcted Glass <br /> New EFEXMWWTanks Sep[ic or Holding Tank /O /006 ,,,r. I�I-n W X• <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 /> e-*Wvw-s Z�S$S I 715- g66- 4157 <br /> Plumber's Address(Street•City,State,Zip Code) <br /> 27- !o o 14w 3S �B �4g 3 <br /> ,Vjll. CountyDepartment Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Iss got nature(No Stamps) <br /> Surcharge Fee) <br /> ElOwner Given Initial Adverse . 6-D 5 A�3 <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> 4pq <br /> Attach complete pian(to the County only)for the system on paper not less than 31/2 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br /> / <br />