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Safety and Buildings UIVISIon county <br /> ., 201 W. Washington Ave., P.O. Box 7162 Q,4rn et <br /> 1- <br /> I sconsii� Madison,WI 53707-7162 Site Address <br /> Department of Commerce 6o Ro( r4 <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide /G <br /> nay be used for second purposes PrivacyLaw,say. I (m Check if Revision �vU J 5,Z <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> 14Aek Whites/de 0019' - 4//9-arra/ <br /> Property Owner's Mailing Address Property Location QV,£ cot <br /> 9o4e/ G t-Ael _Srf. ''A 'A:S /9 T 40 N,R/y <br /> City,State Zip Code Phone Number Lot Number ( Bleck Numb <br /> Subdivision` nNaame CSM Numbe <br /> wauXaI WL -,r9 4W '7/.s^ 8ris= Ole 7 �/► llV. ILJ I�,��. <br /> II.Type of Building(check all that apply) Doty <br /> 611 or 2 Family Dwelling-Number of Bedrooms .4 ❑Village <br /> ❑Public/Commercial-Describe Use <br /> WTownship JLI& t7" <br /> ❑State Owned Nearest Road <br /> Go ?d R <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicabh.) <br /> A. I 0 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> 5 stem Tank Onl Existin S stem <br /> B• ❑ Check if Sanitary Permit Previously Issued 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 20 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Gado 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersaUTreatment 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 /> 300 S ao 336 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sieel Fiber Ph,;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank 7X0 - <br /> Dosing Chamber .5`00 <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached pLins. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number TBusiness Piton o Number <br /> ?rck fie E;ns 24.AAA.oe �ItSBs"-/ 7(�X66-4/.5-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a 7760 /Kr. 3S- ule,6S er, rvr <br /> VIII Count /De-art Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Age nature tate ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse lO <br /> Determination <br /> UI. Conditions of Approval/Reasons for Disapproval <br /> I�DoNO G�11 Gaytfaar U 5l tL• q,, 60 b e 9B.G� <br /> "D `` DIM�s�ot� lr Lola Systewt �i=U�J7t�n/ y9, loco OCT <br /> 2004 <br /> 13URNETTCOUNTY <br /> Attach complete plan:(to the County only)for the system on paper not toss than 81/2 s it inches in size ZONING <br /> SBD-6398 (R. 05/01) <br />