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Safety and Buildings Division County 64/1 <br /> ` A 1W 201 W. Washington Ave.,P.O. Box 7162 U/sn) 1!� <br /> mconSIn Madison,WI 53707 -7162 Site Address <br /> Department of Commerce &,ff <br /> Sanitary Permit Application Sanitary Permit N <br /> 1379 umbe ( hhl <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 74"2— v��1 <br /> may be used for secondary purposes Privacy Law,sl5. 1 m ❑ Check if Revision O <br /> I. Application Information-Please Print All.Information State Plan I.D.Number 0 <br /> Pro7Onet's Name Parcel Number <br /> 7 9 e-/ fz e C> ao- <br /> Property Owner's Mailing Address ,( / Property Location -7 j,�o / <br /> 5_6 -J--5-6 .C.l /�/ e. 41) �" SS Sf;S / Tf� N.R�O <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> /( G Subdivision Name �1 CSM,Number <br /> KS <br /> fK{ i /�1zJ s$o6 �0 3s -3ry ,+po1-4A) l► ,(1 er� I i �S <br /> ri.Type of Building(check all that apply) ❑City r <br /> Y1 or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village <br /> ❑Public/Commercial-Describe Use <br /> �ATownship ® tK <br /> ❑State Owned Nearest Roa f / <br /> III.Type of Permit: (Check only one box on fine A(numbering scheme for internal use). Complete line B if applicable) <br /> A. I KNew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I Tank Only Existing System <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44$,Non-Pressurized In-Ground 20 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41❑ Holding Tank 48❑Bingle Pass 51❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 200 yap y 0 z / 7 — 77, / <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 orH _ QOv N6rWC—:''C- C3 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(P ' t) I Plumber's Signa MP/MPRS Number Business Phone Number <br /> d e- 46ebh Lei 769/ Yq -7a�L <br /> Plumber's Address(Street,City,State,Zip Code) <br /> e.J GJ Sye7,2- <br /> VIII. County/Department Use Only <br /> roved ❑ Disapproved Sin BPermit Fee(includesGroundwater Date Issued issu gentMetmammps) <br /> ❑ Owner Given Initial Adverse .fy �O�( � <br /> Determination a V Y <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system an paper not leas than 81/2 x 11 inches In she <br /> SBD-6398 (R. 05101) <br />