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Safety and Buildings Division County / <br /> ` 201 W. Washington Ave., P.O. Box 7162 U(IVt?7L <br /> iseonsin Madison, WI 53707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> ev <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide I <br /> ma be used for secondpurposes Privacy Law, sl 1 (m) ❑ Check if Rision OO�O <br /> I. Application Information-Please Print Al!Information A 9, State Plan I.D. Number <br /> Property Owner's Name -" <br /> _ Parcel Number <br /> Property Owner's Mailing Address � 6 ;1112A 0 1 00 <br /> QD Property Location 6OV-t /'�T I <br /> City,State 'k b:S 2 T '7 N,R <br /> Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> cs v �8 <br /> II. Type of wilding(check all that apply) 41212- �ZT <br /> �1 or 2 Family Dwelling-Number of Bedrooms 3 <br /> ❑City <br /> ❑ Public/Commercial-Describe Use []Village <br /> El State Owned <br /> ownship U `p <br /> Barest Road Z <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)A. <br /> 1 )f New 2 11 Replacement System 3 C1 Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Onl Existin S Ste— <br /> B. <br /> temB• ❑ 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 7Non-Pressurized In-Ground 21 El Mound 47❑ Sand Filter 50❑ Constructed Weiland <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/Treatment 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./inch) Elevation <br /> yea 610 Sao t TD <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Tanks Plastic <br /> Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /00tH _ _ /Oo0 _/ �� <br /> Dosing Chamber HCl <br /> VII. Responsibility Statement- I,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 /> &_Imoev „�s - zzs$s � = g(- 4►57 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27 7 (o o /4 <br /> V 1. Count /De artment Use Ohl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin g t Signa o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse �d <br /> Determination (/ `f <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> �y SBD-6398 (R. 05101) <br /> a <br />