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I Safety and buildings Division ),curry <br /> —-- — <br /> M �, 20. W. Washington Ave., P.O. Bos 7152 Se,� //I� <br /> isconsin Madison, W 1 53707 -7162 Site Address <br /> _ Department of Commerce 371r H1erp✓5 <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,W is.Adm. Code, personal information you provide ❑ Check if Revisionr� r <br /> _ _ ma be used for second purposes Privacy Law, sIS.04 t)(m) A4 7D v,7 ZZ n l <br /> I. Applicatiow Information-Please Print All Information Stare Plan I.D. Number Y� <br /> Property Owner's Name Parcel Number <br /> sLa u n 7- O ld. - 04/00 <br /> Property Owner's Mailing Address Property Location v l�3 <br /> is 733 /.�iaanon ft>cL r� u;s / r YO N. <br /> City,State Zip Code 7Numbcr, Lot Number BI(ck Number <br /> 12 <br /> Subdivision Name CSM Numbe <br /> U0.//a M/1/ SS/�4 v o+0$ S m V. <br /> II.Type of Building (check all that apply) ❑City <br /> 19 1 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑Public!Cornmercial-Describe Use Township JaGAC"ol <br /> ❑State Owned Nearest Road ''pp <br /> IIII.Type of Permit: rY <br /> (Check only one box on line A (numbering scheme for internal use). Complete line B if applicably.) <br /> A. I El New 2 qr Replacemer4 System 3 ❑ Replacement of 1 6 ❑ Addition to For County use <br /> System Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dam Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44.r 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 F ow (gpd) Dispersal Area Dispersal Arra Soil Application Percolation Rale System Elevation Final Grade <br /> Required Proposed Ram(Gals./Days/Sq.Fr.) (.titin./Inch) Elevation <br /> 3 ea v� q e13,L 7 — 9�•s_ 10s•S- <br /> -VI—Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber Ph :tic <br /> Gallom Gallows of Tanks Concrete Constructed Glass <br /> New Exi:dna <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Dosing Chamber .P00 S�0 <br /> VII. Responsibility Statement- 1,the undersigned, assssme responsibility for installation of the POWTS shown on the attached pi..W. <br /> Plumber's Name(Print) Plumber's Signature MP/ IPRS Number Business Phorr.Number <br /> 2Iele f/o ��S ?.kGi'i p�ir., �d s—S•� 7/S= �6 -'//mss'7 <br /> Plumber's Address(Street.City,Slate,Zip Code) —f <br /> �776a Hwy 3.f tv s S'q 893 <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Salutary Permit Fee(includes Groundwater Date Issued Issuing A Si nature <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse (�� I�j/ <br /> Determination Yf U <br /> I7C. Conditions of Approval/Reassoos for Disapproval <br /> Atuch complete plans(to the County only)for the system on paper not less than&V2 s 11 inches in sue <br /> SBD-6398 (R. 05/01) <br />