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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Its,consin Madison,WI 53707 -7162 Site A cess <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> soIn accord with Comm 83.21,Wis,Adm.Code,personal information you provide *2/7? e'7�� <br /> may be used for secondarypurposes Privacylaw,s15. t m 11 Check if Revision 'Tc J ( l <br /> I. Application Information-Please Print All Information State PI D.Number ~I <br /> a� g3 (0 <br /> Property Owner's Name Parcel Number <br /> CSR p2o 3 060 <br /> ProprtOwnerr''s Mailing <br /> Address / Property Location <br /> S4U, s/ f�- /v 'A A;S::�-7T N,R 6 <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> 533 gQ Subdivision Name Ash/"hMbw <br /> II.Type of Building(check all that apply) 3 ❑City <br /> I or 2 Family Dwelling-Number of Bedrooms OVillage <br /> ❑ Public/Commercial-Describe Use []Township <br /> ❑State Owned Nearest Road <br /> 0 Snlfn 5S <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> INew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank Only Existing S stem <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 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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./Itch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed I Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank Dnh _ no <br /> Dosing Chamber (to//oVV VDO <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 /> cl`FHaevqb PX//Js 2.zS$S 1 7!S- $66- QiS7 <br /> lumber's Address(Street,City,State,Zip Code) <br /> 2.7 7 (oo }-}w 315 �B _�4573 <br /> County/Department Use Ofily <br /> Approved 11 Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu' Age igna e o Stamps) <br /> Surcharge Fee) �} ! <br /> ❑ Owner Given Initial Adverse y.1 aj CTD 'S'p�(� ` <br /> Determination fi _ <br /> i <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> ,y4y <br /> Attach complete plans(to the County only)for the system on paper not less than 8112s 11 Inches lawp YA_ <br /> SBD-6398 (R. 05101) <br />