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*— <br /> Safety and Bullmngs llrvtston county <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> isevnsin 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 Check if Revision �(,7,Z <br /> may be used for second ses PrivacyLaw,sIS.04(1)(m <br /> I. Application Information-Please Print All Information State Plan I.D.Number CYC <br /> J <br /> Property Owner's Name Parcel Number <br /> 6 <br /> PropertyOwner's Mailing Address Property Location meg' <br /> a� 37j Sf A:S6 T_7? N.RE <br /> City,Sate Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM NumtK <br /> wIr 5yee Cl y93 / 7 V 3 37 <br /> ,III.Type of Building(check all that apply) 2 ❑City <br /> 41 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑Public/Commercial-Describe Use '�- <br /> 1;rXownship 4 5 <br /> ❑Sate Owned Nearest 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 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County nue <br /> S stem Tank Only Existing astern <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 /> 44,19-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.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.Ft.) (MinAnch) Elevation <br /> ��d yap vso _ 6'7� <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sieel Fiber pb;Aic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existins <br /> Tanks Tanks <br /> Septic or Holilft-ftakt OAU / J <br /> Dosing Chamlxr O <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Si ature MP/MPRS Number Business Phon:Number <br /> ��e �v`S���ij, GcJ� 2z767/ <br /> Plumber's Address(Street,City,State,Zip Cody <br /> Sok S/Y site � . 7 ;:;L <br /> VII . Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Art ignature(No ps) <br /> Surcharge Fee) <br /> C1 ` / / <br /> Owner Given Initial Adverse 4Qj / 1 tJ / -05 f / <br /> Determination •u V fO J <br /> U. Conditioru of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 s 11 inches in size <br /> SBD-6398 (R. 05/01) <br />