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. Garayan ernAve., UrvisionBo 71 D County <br /> isconsin 701 W.WasMadison, <br /> WI Ave"P.O.Boz 71 13wr n <br /> Madison, WI 53707-7162 Sie Address <br /> Department of Commerce 5 <br /> Sanitary Permit Application SailiratyPennitNumber <br /> In accord with Comm 83.21,Wis.Adm. Code,personal informadon you provide 3 q�cft;; <br /> may be used for secondary es Privacy Law.s15. 1)(m) ❑ Check i Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number p <br /> Property Owner's Name 2 2��aQQ ' <br /> Parcel Number <br /> 13 ilt a- L/ndat rrtvi foh 0/9— -33oa — o j�'jlO <br /> Property Owner's Mailing Address <br /> Property Location <br /> City,State? f v2 P Phone Number -5W SW `4•S T 39 N,R 6 E ! <br /> Li Code I Lot Number <br /> Block Number � <br /> i <br /> Sf <br /> Subdivision Name CSM Number f'ak,l JY) N, SX-,O 7r bx1- -7 7J- d.�.oA <br /> R.Type of Building(check all that apply) <br /> ❑City <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 3 <br /> ❑Public/Commercial-Describe Use <br /> ❑Village <br /> ❑State Owned ®Township m e em oil <br /> Nearest Road �t ee <br /> M.Type of Permit: (Check only one box on line A (nnmbering scheme for internal use). Complete line B if applicable) <br /> EA. 2 Replacement System 3 ❑ Replacemem of 6 ❑ Additionto For County use <br /> Tank Only E❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apprn <br /> apply) scheme is for internal use) <br /> 44 11Non-Pressurized In-Ground A Mound 47❑ Sand Filer 50❑ Constructed Weiland <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 Elevaaen Final Grade <br /> Required Proposed Rae(Gals./Days/Sq.Ft.) (Min./Inch) I Elevation <br /> y so 90 .504 q q6. s2 ; fig• �s <br /> VI.Tank Info Capacity inTotal Number ( Manufacturer Prefab Site Steel I Fiber Plastic <br /> Gallons Gallons of Tanks I Concrete Constructed Glass <br /> New Existing i I i <br /> T Tanks - <br /> Septic or Holding Tank <br /> Dosing Chamber Q411 Z(900 iO <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) <br /> /1' (Print) P!umberr''sSiignature MP/MPRs NumberI Business Phone Number <br /> ePgjS� � ( SerPlumber's Address(S¢ e C , zipCode) f9O6 <br /> 64�-= 4J�77 <br /> j 2.7-7 &0 4w 35 � X48 3 <br /> _VU1. Count /De artment Use Ofily <br /> pproved ❑ Disapproved Sanitary Permit Fee(includes Grotualwater Date Issued Issuin . gcnt Signature!No Stamps) <br /> Surcharge Fee) <br /> I n Owner Given Initial Averse C 1-n <br /> I Determination -�S U "D <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less than 812 x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />