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Safety and Buildings Division County/ <br /> xx 201 W. Washington Ave.,P.O.Box 7162 { t4 '/✓ <br /> isevnsin 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 ❑ Check if Revision 4476 <br /> may be used for secondary purposes Privac Law,s . 1 m O <br /> I. Application Information-Please Print All Information _ State Plan I.D.Number <br /> Property Owner's Name t l Parcel Number <br /> Rfc h W `SN1 e w3 k/ o /;2 S'S `'O o 7oC7 <br /> Property Owner's Mailing Address Property Location <br /> 3 1S C� X14 S , c 'k '!.:Sd.2_3 T 410 N,R E <br /> City,State Zip Code Phone Number LotJNumber Block Number <br /> R�N�C � Subdivision Name CSM Number <br /> /j'1 5 50 5-o7 36'1d7 O g e r Al*je 440170-0 V (/ <br /> H.Type of Building(check all that apply) L ❑City <br /> A or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑Public/Commercial-Describe Use ownship C_ 5 <br /> ❑State Owned Nearest Road �`� ���� <br /> 0L/ e—V f <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 XNew 2 ElReplacement System 3 ElReplarement of 6 ❑ Addition to For County use <br /> System Tank Only Exis' S sum <br /> B. El check if Sanitary Permit Previously Issued <br /> 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 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 Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <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 Hokitg-T** t?od — _ Q J _7L <br /> Dosing Chamber O <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 /> Plumber's Address(Street,City,State,Zip Code) <br /> If A-) <br /> VIJI. County/Department Use Onl <br /> Approved El Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing t Signam o Stamps) <br /> Surcharge Fee) L <br /> El Given Initial Adverse yl <br /> Determination `I(' (/ <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete pians(to the County only)for the system on Paper not less than 81/2 x 11 inches le size <br /> SBD-6398 (R. 05/01) <br />