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Safety and=Buildingsn County201 W.Washingox 7162 Nisconsin Madison, 2 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Per Number /C 4 d$?94 <br /> 1)9 In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision / 9 9L <br /> may be used for secondary purposes Privacy Law,s15. 1 m <br /> I. Application Information-Please Print AB Information State Plan I.D.Number <br /> /00,3037 rob <br /> ro <br /> Propeo Owner's Name Parcel Number <br /> AU e- �q`7�SGlre O/� 3335 a5 3ov s <br /> Property Owner's Mailing Address / Property Location <br /> 10 0 / 3s2 e % i'A;S35"T39 N,R/L <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> cl GiL, 2. <br /> Subdivision Name CSM Number <br /> H.Type of Building(check all that aPP1Y) ❑City <br /> 91 or 2 Family Dwelling-Number of Bedrooms []Village <br /> ❑Public/Commercial-Describe Use Township B N 0 <br /> ❑State Owned Nearest Road <br /> ffw 70 <br /> III.Type of Permit: (Check only one box online A(numbering scheme for internal use). Complete line B 9 applicable) <br /> A For County use <br /> 1 ❑ New 2 Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank OnlyExisting System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(nurnbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 21VMound 47❑ Sand Filter 50❑ Constructed Wedand <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(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 3®/ l <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 HaWiag Fwth 7,3 O 7s 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( ' t) I Plumber's Signa MP/MPRS Number Business Phone Number <br /> 14)461e- eci�f�io n7 <br /> Plumber's Address(Street,City.State,Zip Code) <br /> �6k spy -:5-yz9721- <br /> VIII. County/De artment Use Only <br /> Approved El Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signature ps) <br /> Surcharge Fee) , <br /> ❑ Owner Given Initial Adverse z�O °� f .� -0it <br /> Determination J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less than 81/2 x 11 Inches In she <br /> SBD-6398 (R. 05101) <br />