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Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> Ivisconsinadison,WI 53707 -7162 Site Add ss ,t" Q_ <br /> Department of Commerce &5+ <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> may be used for secondary purposes Privacy law,s15. m) .— <br /> I. Application Information-Please Print All Information State Plan LD. Number <br /> Property Owner's Name Parcel Number <br /> Property Owner's Mailing Address Property Location <br /> 31()q fAILV 1104E 0. ti s::S /4 T 46 N. R 17 <br /> City,State Zip Code Phone Number Lot. Block Number <br /> Subdivision Name CSM Number <br /> A :: 2) L <br /> H. Type of Building(check all that apply) ❑City <br /> �)l or 2 Family Dwelling-Number of Bedrooms �— []Village ��" <br /> ElPublic/Commercial-Describe Use ,Township Am rpt,) <br /> State Owned <br /> Nearest Ro d <br /> ❑ e j <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) j <br /> A For County use <br /> 1 New 2 Replacement System 3 11 Replacement of 6 ❑ Addition to <br /> S stem I I Tank Only Existing Sy stem <br /> Permit Number Date Issued <br /> B. El Check if Sanitary Permit Previously Issued I <br /> IV. <br /> (((���T,,,ype of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> El44 tp�Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50 Constructed Weiland <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.DIs ersaUTreatment 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.F[J (Min./Inch) i Elevation <br /> 300 4-7-1 4.-3Z - -� Rs �')•3 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Construcred Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Dosing Chamber 5vo .� <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> is Si nature MP/MPRS Number Business Phone Number <br /> Plumber's Name(Print) Plumber's g <br /> c{}f}ffZD r/S - 2255$5 f 7lS- $66- 44- 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27 7 &n f-{w �515 <br /> VIII. County/Department Use 1 <br /> Sanitary Permit Fee(includes Groundwater Date Issued Isstf g ent Signature( 0 mps) <br /> roved ❑ Disapproved Surcharge Fee) Pz- / ,1 <br /> ❑ Owner Given Initial Adverse / O(�t �� /V /yl <br /> Determination <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 />