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Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 f1IJ ' <br /> ` ►seons►n Madison,WI 53707 -7162 Site Add ss QQ� <br /> Department of Commerce �v <br /> Sanitary Permit Application Sanitary Permit Number i <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision y/S©65 <br /> may be used for secondary purposes Privacy Law, 5. 1 m) <br /> I. Application Information-Please Print All Information 62:42003 State Plan I.D. Number <br /> Property Owner's Name Panel Number I <br /> R -7 616-3qr -na-3ao <br /> Property Owner's Mailing t�AddreessProperty Location <br /> f i q{p Coti -f P cA SE -A 4:S T N,R <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> � <br /> ` �A O Subdivision Name CSM Number <br /> TJf�0!7tt►zy l `C <br /> i <br /> H.Type of Building(check all that apply) 3 ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms ❑Villa e <br /> 8 I <br /> ❑Public/Commercial-Describe Use segownship U�W <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 it applicable) <br /> A. 1 New 1 2 ❑ Replacement System 1 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> sum 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 rue) <br /> 44�on-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑Bingle 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(Gals./Days/Sq,Ft.) (MindInch) Elevation <br /> ¢Sro foo qoo . 5 96.3 qq. <br /> 0 <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 1000 0 0 0 '✓0 2 a./£$C O <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 /> L4ARJ) ,r/s 2-ZS 8 s' r S66- q-I S7 1 <br /> lumber's Address(Street,City.State,Zip Code) <br /> 277-7 &0 14w 35 � , _54SJ3 <br /> VIII. County/ eartment Use 1 <br /> Sanitary Permit Fee(includes Groundwater Date I sued Issuing Agent S' nature(No S p <br /> pproved ❑ Disapproved Surcha>hYc Fee) `J,� <br /> ❑ Owner Given Initial Adverse <br /> 0-0 Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plants(to the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05/01) <br />