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Safety and Buildings Division County / <br /> *islconsin <br /> 201 W. Washington Ave., P.O. Box 7162 U Madison, W1 53707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Coram 83.21,Wis.Adm. Code,personal information you provide <br /> ma be used for second ses PTIVavv Law,s .04(1 m) 11 Check if Revision v <br /> I. Application Information-Please Print All Information ` State Plan I.D. Number 0f <br /> Property Owner's Name ' Parcel Number V) <br /> 029 y <br /> Property Owner's Mailing Address Property Location <br /> AJ <br /> City,StateZip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> e ss 635- 33�3 1 o rq CSM Y Ib .7 <br /> II.Type of Building(check all that apply) ❑Ciry <br /> kI or 2 Family Dwelling-Number of Bedrooms Z <br /> ❑Village <br /> ❑Public,/Commercial-Describe Use <br /> El State Owned Nearest <br /> (— <br /> Nearest Road <br /> �a <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B applicable) <br /> A. I Y New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Ord Existin 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 21❑ 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 Svstem Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) •-••�.;.,n <br /> SOD Gao tS� • S � - �•� 9?� <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> inExisting <br /> TanksSeptic or HoldingTankDosing Chamber <br /> VII. Responsibility Statement- 1,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 /> e*Ro¢v /,Ws 2ZSSS / 7/.5= S&6- 444S7 <br /> Plumber's Address(Street,City,Stare,Zip Code) <br /> 27 7 (o o ¢}w jS £s �48 3 <br /> VIM. Count /De artment Use 061v <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing nt S' nate o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination i(Y Ae 0 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 05101) <br />