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Safety and Buildings Division t:ounty <br /> 201` W. Washington Ave., P.O. Box 7162 Qurh-e if isevnsin Madison,WI 53707-7162 Site Add' <br /> %,,,,, <br /> Department of Commerce -.r <br /> ` <br /> Sanitary Permit Application Sanitary Permit Number xJ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide Check if Revision <br /> �- D <br /> a td be used for secondary nes Privacy Law,s15. 1)(m <br /> ❑ <br /> rn <br /> I. Application Information-Please Print All Information I State Plan LD.Number <br /> Property Owner's Name Parcel Number <br /> Glyn v Lomas faSer <br /> 01a <br /> Property Owner's Mailing Address Property Location <br /> 3 00 b N. 4xb"V- Sr u u:S /! T 90 N.R/S <br /> City,State F-5-s-1/3 <br /> Phone Number Lot Number <br /> mber Bleck Number <br /> Subdivision Name CSM Numbs <br /> Ifesevtlle 11111/7 Al. q(•a <br /> II.Type of Building(check all that apply) ❑City <br /> Qr1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village <br /> ❑Public/Commercial-Describe Use Wownship JAe�So n <br /> ❑State Owned Nearest Road <br /> 94,n bow C7` <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal use). Complete line B if applicable) <br /> A. 1 rNew 2 ❑ Replacement System 3 ❑ Replacement of 6 11 Addition to For County use <br /> S stem Tank Ordy Existim S ttem <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 kU Non-Pressurized In-Ground 210Mound 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 Sod Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> .7 9�• 8 96• o <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sicel Fiber Pll ;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /000 A-1 <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plsns. <br /> Plumber's Name(Print) Plumber's Signature <br /> MP/MPRS Number Business Phom Number <br /> C_le- 1-101at s �r�a tE+a+�/ L d--r �i 911,6 - S�/s 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 yw 3s- 1� _5-' 8193 <br /> I. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing est tgtntule Stan ps) <br /> Surcharge Fee) �!] <br /> ❑ Owner Given Initial Adverse <br /> Determination v <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system en paper not less than al/Z x 11 inches in sine <br /> SBD-6398 (R. 05/01) <br />