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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 ��✓� <br /> ` Madison,WI 53707-7162 Site Address <br /> isconsin <br /> Department of Commerce sanitary Permit Number <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision J <br /> ma be used for secondary ses pri acy Law,sl5. 1 m) State Plan I.D.Number 06 <br /> I. Application Information-Please Print All Information <br /> Parcel Number <br /> Property Owner's Name <br /> er!' / 'Ii � j <br /> p Location G <br /> Property Owne-fs Mailing Address '" � <br /> �/no (Je A A) 'A, T'3� N,R( SE <br /> Zip Code Phone Number Lot Number Block <br /> City,State <br /> Subdivision Name CSM Number <br /> L` e trNofCl A) s5117 <br /> H.Type of Building(check all that apply) ❑City T <br /> ❑Village <br /> *-or 2 Family Dwelling-Number of Bedrooms <br /> �� <br /> ❑Public/Commercial-Describe Use ownship ��3�� <br /> Nearest Road r <br /> ❑State Owned C^/9'��e-l/` /1) 5 <br /> Ill.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable <br /> A. 1 ew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> For County use <br /> S stem Tank Only Exist;__ S stem Date Issued <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) 50 El Constructed Weiland❑ Non-Pressurized In-Ground 21�.Mound <br /> 47❑ Sand Filter <br /> 41❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 22 11 Pressurized In-Ground 30❑Other <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating <br /> V.Dis ersal/Treatment Area Information: Percolation Rate System Elevation Final Grade <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Elevation <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) <br /> Sao 506 � o � �/ `- 7f o, g' <br /> Ca aci in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> VI.Tank Info P ty Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank -5 <br /> Dosing Chamber Qtb ' .5D <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the,attached plans.s Phone bet <br /> plumber's Signature MP/MPRs Number <br /> Plumber's Name( t) // 76 �1 j -7 <br /> e Im <br /> plu'mbber's Address(Street,City,State,Zip Code) <br /> en <br /> VIII. Count /De artment Use Only <br /> Sanitary Permit Fee(includes Groundwater Dau Issued Issuing n ignamre o S ps <br /> Approved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Initial Adverse I <br /> Determination <br /> IX. Conditions of ApprovallReasons for Disapproval <br /> Attach complete plana(to the Coma 0017)for the syat�un pates'not less than 81/2 a it l0ches m alae <br /> SBD-6398 (R. 05/01) <br />