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` Safety and Buildings Division County ^ _ <br /> Ww?Ar 201 W. Washington Ave., P.O. Box 7162 y <br /> w sconsr►n Madison, WI 53707-7162 Site Address <br /> Department of Commerce �p <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> ri ❑ Check if Revision <br /> a be used for second purposes Privacy Law, 5.04 1)(m <br /> I. Application Information-Please Print All Information �)� State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> Property Owner's Mailing Address Property Location <br /> 6(/ 8- ,-, U �A 9:S90T T'-',/moo / <br /> N.R G <br /> City,State Zip Cade Phone Number Lot NumberBlack Number <br /> pp Subdivision Na, a CSM Numbe <br /> 7 <br /> Zo fL G-A¢o41,U/'�- ,4ja/ <br /> II.Type of Building(check all that apply) Dory _ <br /> 91,or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑Public/Commercial-Describe Use — <br /> 1¢wc� <br /> ❑State Owned Tzkownship <br /> Road <br /> 730 <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal use). Complete line B f applicabh!) <br /> ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to I For County use <br /> S stem Tank I dog System <br /> B. ❑ Check if Sanitary Permit Previously issuedr rmit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,9-Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 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 Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> ado 471�2 19 93_,_-P 9,';::"o <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab <br /> Site Sieel Fiber pi;,;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or g-Tatk <br /> Dosing Chamber OtlY11)10 157 eJ <br /> " <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached ph ns. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,eo_L, .tel <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A nature(No 1 Ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse 2✓� �// �� <br /> Determination ✓ rP <br /> L$. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x It inches in size <br /> SBD-6398 (R. 05/01) <br />