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Vor. Mir <br /> /sconsin 201 W. Washington Ave.,P.O. Box 7162 <br /> Madison,WI 53707-7162 Site Address <br /> Derlartment of Commerce <br /> Sanitary Permit Application Sway Permit Number <br /> In accord with Contin 83.21,Wis.Adm. Code,persorol information you provide ������ j <br /> ma used he for sero s Priv Law.sty. t)(m) ❑ Check if Revision <br /> I. Application Information-Please Print All Information Sate Plan I.D.Number J <br /> -3 <br /> Property owner's Name 3 , <br /> Parcel Number <br /> Parol G0.11er Dla ` /d.a, - <br /> Property Owner's Mailing Address O/900 <br /> Property Location <br /> IDO ffivaitd• /9✓e. /V9-% NK/%;S /3 T 4D N.R <br /> City,Sate Zip Code Phone Number Lot Number Block Number <br /> Swq � <br /> Subdivision Name CSivl Number <br /> fionkw 104- /Y)/l/ SS`33 / Deer Lodge t*.V. to V.v. <br /> U.Type of Building(check all that apply) <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms ❑City <br /> 11Public/CommercialoPublic/Commercial-Describe Use ❑Vt7lage ! <br /> (Township tAe-k son <br /> 11 Sate Owned Nearest Road <br /> rJezr7eale Pa SS <br /> M.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 � New 2 ❑ taeemem For Co use <br /> Rep System 3 ❑ Replacement of 6 ❑ Addition m County <br /> stem T�OnlyS stem <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 interna(use) <br /> 44 A Non-Pressurized In-Ground 210 Mound 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 Soil Application Percolation Rate7Con=sa=mred <br /> Final Grade <br /> Required Proposed Rax(Gals.Mays/Sq.FL) (Min./Inch) Elevation <br /> 300 `13 �`3oL VI.Tank Info Capacity in Total Number Manufacturer Prefabl Fiber PlasticGallons Gallons of Tanks ConcreGlass <br /> New Faisting <br /> Tanks Tanks <br /> septic or Holding Tank tv <br /> Dosing Chamber /C <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 <br /> /MPRS Number Business Phone Number;P =ms <br /> 4 57 <br /> Plumber's Address(Street.City•State,Zip,Code) <br /> 2.77 (oo 14W :315 �g I , �4S 3 <br /> VIII. Coun /De artment Use Ofilyi <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu' A t Signatu o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse (� '/r <br /> Determination �L r D3 <br /> LY. Conditions of Approval/Reasons for Disapproval <br /> i <br /> Attach complete plam Ro the County duly)for the system on paper not cess than 91/2 x 11 laches to she <br /> SBD-6398 (R. 05101) <br />