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Safety and Buildings VMS= joumyk' <br /> 201 W. Washington Ave.,P.O.Box 7162`�SCOf1Sln Madison,WI 53707-7162 A-dDepartment of Commerce (e55 �i� . Fdr {'aid <br /> Sanitary Permit Number <br /> Sanitary Permit Application 445 _73 ,I <br /> In accord with Cotrim 83.21,Wis.Adm.Code,personal infor ation you provide ❑ Check if Revision tin be used for second sea Privac Law,s15. 1)(m State Plan LD.NumberI. Application Information-Please Print All Information <br /> Property Ow is NameParcel Number oroperty Location <br /> Property Owner's MaA ress 13 'a u:S Tjq&R I <br /> City,State Zip Code Phone Number Lot Number Black Number <br /> Subdivision Name CSM Numbe <br /> n�e r <br /> 1A..9 r OF ( M <br /> 1,31y..Type of Building(check all that apply) OCity _ <br /> &or 2 Family Dwelling-Number of Bedrooms ❑Village — <br /> ❑Public/Commercial-Describe Use ownship <br /> Nearest Road <br /> ❑State Owned <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B if applicable) <br /> A For County use <br /> 1=steTank <br /> em 3 ❑ Replacement of 6 ❑ Addition to <br /> STank OnI Exis'B. ❑ Issued <br /> Pctmic Number <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Y]� <br /> .,,,(Non-Pressurized In•Grouod 210 Mound 47❑ Sand Filter 50❑ Constructed Wedand <br /> 41 ❑ Holding 22 C1 Pressurized In-Ground m8 Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45 11 At-Grade <br /> 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersaVTreaIN17; <br /> formation: <br /> Design flow(gpd) a Dispersal Area Soil Application Percolation Rale System Elevation $�evationde <br /> Proposed Rate(Gals./Days1Sq.Ft.) (Min./Inch) Qy l �Q <br /> Coo � a , 7 ¢t ? ,VI.Tank Info in Total Number ManufacturerPrefab Site Sieel Fiber Plr;tic <br /> s Gallons of Tanks Concrete Constructed GlassistingD / _�f,�5,�anks IN <br /> Septi r Holding Tank - <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the ersigned,ass responsibility for installation of the POW IS shown on the attached pfa.tss. <br /> Plumber's Name Print) Pl her's Signatu MP/MPRS Number Business Pbon:Number <br /> �' 7tS 4'�s <br /> P umber's Address( et,City,State,Zip C e) <br /> VUl. Count /De artment Use Onl ( ps) <br /> Sanitary Permit Fee(includes Groundwater Datc Issued Issuing AS NTe <br /> CK"Approved C1 Disapproved Surcharge Fee) ��pq <br /> ❑ Owner Given Initial Adverse <br /> Determination YYKK <br /> LX.Conditions of Approval/Reasons for Disapproval l <br /> APR7 - 20RURNETT I <br /> r _ <br /> Attach complete Plain(to the County only)for the system on paper not less than 8113 s It inches io size 2ON1A'"^"' r [ <br /> SBD-6398 (R. 05/01) tYV <br />