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`Ar Safery and Buildings Division County <br /> iw � 201 W. Washington Ave., P.O. Box 7162 <br /> sevnsin Madison, WI 53707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary PPeFnt N , be 9J <br /> In accord with Comm 83.21,Wis. Adm. Code,personal information you provide <br /> may he used for wrondary purposes Privacv law 15.04(1)(m) "7Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number �+ <br /> Property Owner's Mame <br /> Parcel Number <br /> 3- <br /> Property Owner's Mailing Address <br /> Property Location <br /> �:s � T N. R � <br /> City,State Zip Code Phone Number Lot Njimber Block Number <br /> 507 4',51- 7096 � Subdtvatston Mame CSM Number <br /> G.1 ttTDfs�1 /�/ JS��D <br /> V. Iq <br /> II. Type of Building(check all that apply) ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms 2 <br /> l ❑ Public/Comm ❑Villageercial-Describe Use <br /> ❑ State Owned IXiTownshio 5W t`25 <br /> Nearest Road <br /> co. F <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A.- <br /> I )�New 2 ❑ Replacement System 3�Repla��memof6 ❑ Addition to For County use <br /> S stem TExistin System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit dumber I 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 Treatmenr Unit 49❑Recirculating 30❑Other <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area i Soil Application <br /> Percolation Rale System Elevation Faal Grde <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) i q✓�7 Elevation <br /> 344 yZ9 y3z v -7 ff 5 7 <br /> ' �rH.S � <br /> VI. Tank Info Capacity inTotal Number I Manufacturer Prefab Site Steel I Fiber P!astic j <br /> Gallons Gallons of Tanks Concrete Constructed I Glass <br /> New Existing <br /> Tanks Tanks II I I <br /> Septic or Holding Tank / CV W <br /> _ l®eto I 1 ArOCP�'(y <br /> Dosing Chamber I vW <br /> � I <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 /> z�5$ S f 7�S- g66- 44i 77 <br /> Plumbers Address(Street,City,Stare.Zip'Code) <br /> 277100 14w-� �S (,IBSIZ ill �4g`�3 <br /> Y1 n <br /> . l.uwLLYILC ill IILLClIL VAC Vin <br /> I <br /> pproved ❑ Disapproved Santa r Permit Fee(Licludes Groundwater j Date Issued ! Issuing gem Signe Stamps) <br /> Surcharge _eel /I i <br /> ❑ Owner Given Initial Adverse P�71 <br /> Determination 00 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> I <br /> Attach complete plans(to the County only)for the.system on paper not less than 91/2 x 11 inches in size <br /> SBD-6398 (R. 05101) <br />