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Safety and Buildings utvlsion county . <br /> ` <br /> 201 W. Washington Ave., P.O. Box 7162 U�Wisconsin Madison, WI 53707-7162 Site Address's <br /> Department of Commerce Iry7Ed a ne <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if �On' 9 <br /> my be used for secondarypurposes PrivacyLaw, 15. 1)(m <br /> I. Application Information-Please Print All Information StatePin I.D. Nher <br /> Property Owner's Name Parcel NumberbaU_3� _ <br /> c� r 07O,lyo2 /1/0.3-505 73 Uuti3 oO <br /> Property Owner's Mailing Address Property Location h <br /> 410Ji S. VOII. _ 3 S TJ N. R I <br /> City,/State ,/ Zip Code Lot Number BlccM/Y lCC/I1,Pho;Number <br /> /�3 y_ O6 Subdivision Name CSM Numbe <br /> 70sas <br /> CM V I P a-- Gov Lora v s39 <br /> n.Type or Building(check all that apply) ❑City _ P-?/ <br /> te <br /> 44 or 2 Family Dwelling-Number of Bedrooms []Village <br /> ❑Public/Commercial-Describe Use- $Township 0 — <br /> ❑State Owned Nearest Rad <br /> Cane <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicabht) <br /> A. 1 ❑ New 2 AI Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Drily Existing System <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 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 K Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatmeut Area Information: <br /> Design Flow(gpd) Dispersal Arca 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 SiceIFiber PJ; aic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic o Holding TaNc <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached phis. <br /> Plu isp ame fPrint Plu ber' tore MP/MPRS Number Business Phorr.Number <br /> 'U1 if- e a3oBYy / �3s�rss <br /> lumber's Address(Street,C ,State,ZCode) <br /> W-7dvs F Soo S5'6G <br /> 171 <br /> e aliment Us Onl❑ Diupproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A 4 S rumre(N n ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination /t7n 4M <br /> IX. Conditions of Approval/Reasotss for Disapproval n <br /> �J AUG 2 3 2011 <br /> Attxh complete plans(to the County only)for the system on paper not less than 81Q a t1 IsITV <br /> Zom "1 ► <br /> SBD-6398 (R. 05/01) <br />