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` Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 G//^/t� e <br /> �sconsin Madison, WI 53707-7162 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> Cheif <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide q`' ' �0 (�1 <br /> ❑ <br /> may be used for sero purposes Privet Law,s15. 1 m Revision � <br /> I. Application Information-Please Print AH Information State Plan I.D.Number <br /> Property Owner's Name / Parcel Number <br /> O o 2 70 <br /> Propirtrty Owner's Mailing Address //�� Property Location A C <br /> ttJ e r /I 5Z'J 4 54 '.6:S T Ye N,R <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> T__ I <br /> Subdivision Name CSM Number <br /> h,3ar x`/830 5r�-306-T <br /> II.Type of Buil ' g(check all that apply) ❑City �— -- <br /> or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village <br /> ❑Public/Commercial-Describe Use <br /> ownship <br /> ❑State Owned Nearest Road <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 X�N_ew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank Only Exisi <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 ruse) <br /> 44 VNon-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-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 3o❑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 /> 4/-5-0 94/3 G �� , �7 - 9 Y Y v-*lr <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank foe)tq <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ZI <br /> I Count /De artment Use Only <br /> 0 <br /> pproved L1Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) /1 <br /> ElOwnet Given Initial Adverse <br /> Determination <br /> IX.Conditions of ApprovaMasons for Disapproval <br /> V1 <br /> 2002 <br /> B <br /> Attach complete plans(to We County only)for the system on papa not leu than 81/2 x 11 Inches in size <br /> ZONING <br /> SBD-6398 (R. 05/01) <br />