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Safety and Buildings Division County l <br /> 201 W. Washington Ave., P.O. Box 7162 Afj <br /> V <br /> seonsin Madison, WI 53707 -7162 Site Address <br /> Department of Commerce 3 LiAe <br /> Sanity Permit Number '/� <br /> Sanitary Permit Application Sanitary 7`�3 �� O <br /> In accord with Collum 83.21,Wis.Adm. Code,personal information you provide � <br /> may be used for secondary purposes Privacv Law,s15.04(1)(m) ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number /`,/O <br /> Property Owrier's Name Parcel Number (� � <br /> 4 012 zs vo <br /> PropertyOwner's Mailing Address Pro <br /> perry Location i <br /> 14:S T 7O N. R �j E.W <br /> City, State Zip Code Phone Number I Lot Number Block Number <br /> Subdivision Name CSN1 Number i <br /> u r <br /> II. Type of Building(check all that apply) ❑Cityi i or'_Family Dwelling-Number of Bedrooms <br /> L V illage <br /> ❑ Public!Commercial-Describe Use 1 Townshin J�Ck6o lv <br /> ❑ State Owned Nearest Road AN <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> i <br /> A. <br /> 1 11 New 1 2 ❑Replacement System 3 Replacement of 6 !❑ Addition to For County use <br /> System Tank Only Existin System <br /> Number <br /> Date Issued <br /> B. i ❑ Check if Sanitary Permit Previously Issued Permit Numi <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22 11 Pressurized In-Ground 41 Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ A[-Grade 46❑Aerobic Treatment Unit 49 11 Recirculating 30❑Other � <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation-IFinal Grade <br /> �J Required Proposed Rare(Gals./Days/Sq.Ft.) (Mindlitch) Elevation <br /> � I <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed I I Glass I <br /> New Existing <br /> Tanks Tadts <br /> Septic or Holding Tank <br /> /l <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's`lame(Print) Plumber's Signature MP/MPRS Number: Business Phone Numter <br /> L{{�}4ZD Kii✓S 22S'$S 7!S- g(a6- 4157 <br /> lumber's Address(Street,City,State, Zip Code) <br /> 27 7 &0 144 35 <br /> ,VJAI. County/Department Use Olhly <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date issued Issuing Agent Signamra(No Stamps) ' <br /> Surcharge Fee) ^00I OD I� �1 <br /> ❑ Owner Given Ittitial Adverse (;J=O <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval V{ <br /> \JAS f <br /> QUA �S <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in s <br /> SBD-6398 (R. 05101) ���NG�NTj, <br />