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14sconsin <br /> Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 Madison,WI 53707 -7162 Site Address /J <br /> De ailment of Commerce Z /" e-He <br /> Sanitary Permit Application Sanitary�t Nu,7`o ,# <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide Check if-23ision c;2-7130 <br /> may be used for seen purposes PrivacyLaw,s15. 1 m <br /> I. Application Information-Please Print All Information State Plan I.D. Uumber <br /> Property Owner's Name Parcel Number <br /> n, o ,3 Z6/ 0?- <br /> Property Owner's Mailing Address Property Location <br /> 2375 6k SE':S /S T 36 N,R E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> ,411k 5't 7/ (lis - 25Z7 <br /> II.Type of Building(check all that apply) ❑City <br /> I or 2 Family Dwelling-Number of Bedrooms Z []village <br /> ❑Public/Commercial-Describe Use %Township (� <br /> ❑State Owned Nea st Road <br /> P10 <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete ' e B if applicable) <br /> A. 1 ❑ New 2 r�Replacement System 3 Cl Replacement of 6 ❑ Addition to For County use <br /> System 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 /> 44 ❑ Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Graund 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.DispersalrIWAtment 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 /> 3oe ,p <br /> 40 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> NewaalcFr�ali�v <br /> Ts Tants <br /> Septic or Holding Tank 76O i� <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) IPlumber's Signature MP/MPRS Number Business Phone Number <br /> ,-*VP ,Js 2 2 S$S '�IS g66- 4157 <br /> lumber's Address(Street,City,State,Zip Code) <br /> 2.77 (oo /4w-f 35 <br /> TW <br /> VITT. 3 <br /> VIIIli <br /> . Count Department Use <br /> if Approved ❑ Disapproved Sanitary Permit ee(includes Groundwater Date Issued Issuing Agent Signatur s) <br /> Surcharge Fee D <br /> ❑ Owner Given Initial Adverse V DO ��� 6 yr <br /> Determination V <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 />