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Safety and Buildings Division County <br /> visc nsin 201 W. Washington Ave.,P.O. Box 7162 ,6o f xe, <br /> YMadison, WI 53707 -7162 Site Address <br /> Department Of Commerce 2R4G3 (� ` <br /> Sanitary Permit Application Samtary Permit Number (l�� <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide C v <br /> may he used for secondary purposes Privacy Law 1TZ7��� <br /> El Check if Revision �S�J <br /> I. Application Information-Please Print All Information State PlanI.D. NumberProperty Owner's Name (/ , <br /> Parcel Number I <br /> 'l E eN 07-49 906,,x' OZ 000 <br /> Property Owner's Mailing Address <br /> Property Location <br /> 3s06 ,, A Avw <br /> 1At4;54 T4PN,R16 W <br /> City, State Zip Code Phone Number <br /> Lo[Number Block Number <br /> pq <br /> Subdivision Name CSM Number <br /> 757—J3/ 1O0 LL <br /> H. Type of Building(check all that apply)4AJaver Miv 5,63011f 6 <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑City <br /> ❑ Public/Commercial-Describe Use ❑Village <br /> ❑State Owned Township w -j <br /> Nearest Road <br /> III.Type of Permit; (Check only one box online A(numbering scheme for internal use). Complete line B if applicable) <br /> A 1 Sr New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank OrilX Exist'Existine S sum <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 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 Elevation Final Grade <br /> Required Proposed Rate(Gais./Days/Sq.Ft.) (Min./Inch) <br /> Elevation <br /> • 7 — g3• S qs6 <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 Tanks <br /> Septic or Holding Tank /000 /w , <br /> Dosing Chamber <br /> i <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 /> ,(_*V-P inls 22 S$S I IS g66- ¢�S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2.77 (on `jS �48 3 <br /> I. Count /De artment Use 1 <br /> pproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) } <br /> ❑ Owner Given[nidal Adverse `H, Rm- <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <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 />