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` Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> iseonsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce �Ow �g� , <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 purposes Privacy Law,s15. 1 m) El Check if Revision <br /> I. Application Information-Please Print All Information S X O State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> cve, tgj S0 <br /> Property Owner's Maft Address 7 Property Location <br /> 2 6 kheY/ A) 'k 'b;S A T 410 N,R / <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number j <br /> 15 ffiv 550 SFS/ <br /> H.Type of Building(check all that apply) ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms /? <br /> []Village <br /> ❑Public/Commercial-Describe Use <br /> P`I'ownship (� <br /> ❑State Owned Nearest Road <br /> Ii4j .v <br /> III.Type of Permit: (Check only one bo on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A' 1 New 2 ❑ Replacement Sys te 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> system Tank Onl <br /> Existing System <br /> B• ❑ Check if Sanitary Permit Previously I sued Permit Number Date Issued <br /> i <br /> IV.Type of Permit: (Check all that app y)(numbering scheme is for internal use) <br /> 44 Non-Pressurized In-Ground 21C Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 4111 Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ Ai-Grade 46 13 Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Informati : <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required roposed Rate(Gals./Days/Sq.Ft.) (Min./inch) Elevation <br /> 429 y3z ' -7 gzs <br /> VI.Tank Info Capacity in oral Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Galloon G Lucas of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks j <br /> Septic or Holding Tank /B Po <br /> Armor <br /> Dosing Chamber <br /> I <br /> VII. Responsibility Statement- I,the undi tsigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum is Signature MP/MPRS Number Business Phone Number <br /> ,e-� 4ep pgjpls <br /> Plumber's Address(Street,City,State,Zip Cod ) <br /> 27 7 (oo 14w <br /> V . <br /> County/De artment Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit F�cludes Groundwater Date Issued Issuing A nt Sig rue S mps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adver ie <br /> Determination O` ' <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complele plans(to the County only)for the system on paper not less than 8112 x 11 inches in size <br /> SBD-6398 (R. 05101) <br />