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Safety and Buildings Division Countyfir :78f7i0))3 <br /> Np 201 W. Washington Ave.,P.O.Box 7162 6r ,^ 10 �` isconsin Madison,WI 53707-7162 Site Address <br /> ent of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revisionm be used for seco ses Priv Law, I5. 1 mI. Application Information-Please Print AB Information State Plan I.D.Number <br /> Property Owneis Name Parcel Number <br /> c3 <br /> Property Ow.r's Mailing Address Property Location PC./ <br /> -ASL✓ ,A:S cz U T <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> V /`7' r` d <br /> II.Type of Building eck all that apply) ❑City1 or 2 Family Dwelling-Number of Bedrooms ❑Villa e <br /> / <br /> [I ,rx,, g Public/Commercial-Describe Use pyrownshlp-7—r q U 0 4 JAZ <br /> ❑ State Owned Nearest Road f _/._ <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. I ❑ New 2'0-Replacement System 3 ❑ Replacement of 6 Addition to For County use <br /> S tem I I Tank Only Existing System <br /> B. Check if Sanitary Permit Previously Issued Permit Number 3_5),�� Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) I/j.7S VO <br /> 44 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Welland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 3o❑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 /> 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 <br /> Dosing Chamber I ILIIle z / <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 /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A t ' nature tamps) <br /> Surcharge Fee) <br /> ❑ Owner Given initial Adverse yy�r <br /> �J Cj/l <br /> Determination f'( OC ✓t/ <br /> IX.Conditions of Approval/Reasons for Disapproval 7AUG <br /> Changes /n CodeCom83 t $5Sui.Y /, 2000, Lt(laao 5{adow Incfa/fr~- 16- 12005 <br /> GLala.S0.ccK{ Ea E'><ISYH,s ,�iL A$SDR/�TinJ Cf[C.. <br /> Attach complete plans(to the County only)for the system aBmr UfiII'f ft in else <br /> SBD-6398 (R. OS/Ol) <br /> ZONING <br />