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AF Safety and Buildings Division county/� <br /> so 201 W. Washington Ave., P.O. Box 7162 <br /> `Wisconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide ���2 <br /> my be toed for second ses PrivacyLaw,s15. 1)(m ❑ Check if Revision J <br /> I. Application Information-Please Print All Info ion State Plan I.D. Number <br /> n� agF�a <br /> Property Owner's Name Parcel Number <br /> >`"e s O A C/ 3li o 2 iv <br /> Property Owner's Mailing Address Property Location <br /> / NE ANw <br /> Ch¢jZip <br /> L,g.J a 'A:S IVT39' N.RIyE <br /> City,State de Phone Number Lot Nymber Bleck Number <br /> Swbilt"ston-Nimic CSM Numb, <br /> II.Type of Building(check all that apply) (� ❑City <br /> 0-1 or 2 Family Dwelling-Number of Bedrooms_ T <br /> C1 ❑Village (}�) <br /> Public/Commercial-Describe Use Township T- <br /> ❑State Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A (numbering scheme forinternal use). Complete line B if applicable) <br /> A' )14—New 2 ❑ Replacement System 3 El Replacement of 6 ❑ Addition to For County use <br /> stem Tank OnIv Exictio S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dam Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,�ivon-Pressurized In-Ground 210 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 Unlit 49❑Recirculating 30❑Other <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Area Soil Application Percolation Rate System Elevation Final Grade <br /> Requiredposed Ram(Gais./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 6v0 � S-Y � Y 7 <br /> VI. Tank Info Capacity N Total Number Manufacturer Prefab Site Si cel Fiber Pit;tie <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or lana:...'r..v e;90v — " D D IC !9•� <br /> Dosing Chamber <br /> YII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached pl:ms. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon.:Number <br /> f1) e ��_ zz7G9/ 3s/, 7s� � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Ae"r <br /> VIII. Count /De artment Use A-] <br /> - <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater =hsuedssuing A igtumre(N tali ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plana(to the County only)for the system on paper not los than 91/2 x 11 Inches to size <br /> SBD-6398 (R. 05/01) <br />