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Safety and Buildings Division County <br /> NVisconsin <br /> 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number i90 <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide - <br /> may be used for secondary purposes Privac Law, 5. 1 m) 11 Check if Revision <br /> �D r <br /> I. Application Information-Please Print All Information nState Plan I.D. Number ^�— <br /> Property Owner's Name L Parcel Number U) <br /> i©M 032 91 M 01 Soo <br /> Property Owner's M 'ing ss Property Location <br /> 73 k 4;S 2T nnAA-- <br /> T - N,R 6 E <br /> City,State Zip Code Phone Number Lot W <br /> mber Block Number <br /> Subdivision Name CSM Number <br /> n��xfr 6yB _7� <br /> II.Type of B 'ding(check all that apply) <br /> 2 ❑City � <br /> 71 or 2 Family Dwelling-Number of Bedrooms ❑village <br /> ❑ Public/Commercial-Describe Use <br /> gTownship 'rj <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 19 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I I Tank Only 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 /> " IN Non-Pressurized In-Ground 2111 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 Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System ElevationFittal Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <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 TaNcs <br /> Septic or Holding Tank <br /> Dosing Chamber /4r/t� �bC7t <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 /> CAVP /ds A-= 2z-SS S / 715- S66- 46-7 <br /> lumber's Address(Street.City,State,Zip Code) <br /> 27 7 !o o j'-vv-f 3,5 <br /> VIII. Count !De artment Use Ofily <br /> pproved ❑ Disapproved <br /> Sanitary Permit ee(includes Groundwater Date Issued Issuing Agent Si atur N tamps) <br /> Surcharge Fee <br /> ❑ Owner Given Initial Adverse O a r OD <br /> Determination U( O <br /> IX. Conti' 'ons of ApprovaUReaso s..fnorQDisapproval <br /> S( /��� <br /> � /X�`o�l (i'1- J <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br />