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Safety and Buildings Division County <br /> `vma 201 W. Washington Ave., P.O. Box 7162 (N t� <br /> iseonsin 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 L/-) 3s5` <br /> may be used for secondary purposes Privacy Law,s15. 1)(m) ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> 0/-�- 9/0/- 0/- Q-on <br /> Property Owner's Mailing Address Property Location /� <br /> 9 er4JJG'N 'A 4;S 7 T (11 N,R� E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> l/•j%*/fv- W- S9w 3 757-O V^kUe7 �v <br /> H.Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms _ []Village <br /> ❑Public/Commercial-Describe Use ownshi <br /> p 12ickee5� <br /> ❑State Owned �areQ��Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). 'Complete line B if applicable) <br /> A. 1 ❑ New i 2 X Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank Only Existing System <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 2111 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./Inch) Elevation <br /> 9006 9�o <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank — /Z� �7�f �G.� ✓ <br /> Dosing Chamber 4riv l� <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/MFRS Number Business Phone Number <br /> h�je-4AOZ-p r/s - 2ZS$S 1 715- S(6- 4157 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 277 !o3K <br /> VIII. County <br /> y. <br /> V. e artment Use Ofily <br /> Approved Disapproved Sanitary Permit Fee(includes Groundwater Date Issued I Zi re(No Stamps) <br /> Surcharge Fee) / <br /> ❑ Owner Given Initial Adverse �Z 6(0,CD <br /> Determination 777 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> 00, <br /> ZRti/ <br /> Attach complete phttu(to the County only)for the system on paper not less than 8112 x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />