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Safety and Bulldtngs ulvislon county <br /> 201 W. Washington Ave.,P.O. Box 7162 /'AJ e <br /> `� y ccOnc n 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 N <br /> ❑ Check if Revision <br /> may be used for second ses Privacy Law,s15.04(l)(m S <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> 61 <br /> Proper/ty Owner's Mail' Address n� Property Location ,t <br /> y6 L5 d e /()J (✓ '4!✓� Sf:SA T Yk N.R! -�rE <br /> City,State Zip Code Phone Number Lot Number Bleck Number <br /> Subdivision Name CSM Nurn <br /> -- <br /> II.Type of Building(check all that apply) ❑City _ <br /> PT or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑PubliclCommercial-Describe Use wnship <br /> ❑State Owned Nearest Road <br /> Vese/ <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal use). Complete line B if applicably:) <br /> A. I-JR 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Only Existin S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 449�Non-Pressurized In•Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wedand <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/Treat ent 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.flnch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Si eel Fiber Ph aic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or NeMttig-[ank <br /> Dosing Chamber GG <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached phins. <br /> Plumber's N e(Print) Plumber's Signarur MPIMPRS Number Business Phon:Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII. Count /De aliment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stan ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse oZ 5D. CC) O <br /> Deterntination <br /> IX. Conditions of ApprovaUReasous for Disapproval ��V <br /> Nov <br /> Attach complete plans(lo the County only)for the system on paper not less than 81/2 s 11 i c In sue <br /> BUSNEo NG N t <br /> SBD-6398 (R. 05/01) <br />