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Safety and Buildings Uivlsion county <br /> O <br /> 201 W <br /> � W. Washington Ave.,P.O.Box 7162 <br /> rseonsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce 1211 P m l.tq„�, <br /> Sanitary Permit Application Sanitary Permit Number fff r <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide ❑ Check if Revision 7Q,ty,(Z �w <br /> may be used for sew us PrivacyLaw,s15. 1Hm CJJ 1 lJJ <br /> I. Application Information-Please Print All Information 2 y� ll State Plan I.D. Number <br /> Property Owner's Name f Parcel Number <br /> s)i.VA J�n�e 07,-f'4636_-a[ boa <br /> Property Owner's Mailing Address n Property Location <br /> Ci state I O$ ea cm I vl el i{.'l.£ a u:S )z. T3�► N.R) IJ g <br /> City, Zip Code Phone Number Lot Number /� ck:lumber <br /> & t SIe 1' Bla2- <br /> Subdivision Name CSM Numbe <br /> aliJ%ri44 <br /> U.Type of Building(check all that apply) ❑City <br /> �1 or 2 Family Dwelling-Number of Bedrooms g4,e,!Y£1Cls}nvtE Roo m 216R ❑Village — <br /> ❑Public/Commercial-Describe Use — $IZ.trµ.( — <br /> 7ownship <br /> ❑State Owned Ne at Road <br /> 1 Al..rvl4UL LAT-F, <br /> III.Type of Permit: (Check only one box on line A (numbering scheme forinternal use). Complete line B if applicabh!) <br /> A' <br /> 1X New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> stem Tank Onl 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 Non-Pressurize n- round 21❑ Mould 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Yressuriz d In- round 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recircularing 3o❑Other <br /> V. Di, ersaVTreatment 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 /> 300 2 116-0 . -7 /7'10 -,a h 9/.0 ' ! 93.5 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site SecF Fiber Ph.me <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> RODSeptic eelfeidiR.;--s. _ <br /> 00 r -K <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,t dersimed, a responsibility for instaWon of the POWTS shown on the attached phins. <br /> Plumber's Name(Print) u r s Signa a POS Number Business Phoni:Number <br /> M&K SEPTIC & EXCAVATI P�.a Y879 <br /> PI tgCL. g4 Zip Codc) <br /> 71 -615-7482 <br /> VII Count /Department Use Only <br /> Approved ❑ Disapproved Sanitary Petmit Fee(includes Groundwater Date Issued Issuing a igsnmre tam ps) <br /> Surcharge Fee) /� <br /> ❑ Owner Given Initial Adverse <br /> Determimdon ''RR ilV .Y'r UJ <br /> IX. Conditions of Approval/Reazods for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not Im,than!IRs It inches in size <br /> SBD-6398 (R. 05/01) <br />