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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 <br /> Nvisconsin Madison,WI 53707 -7162 Site Add <br /> Department of Commerce a� N <br /> Sanitary Permit Application Sanitary P(�eernutit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,persomal information you provide -C] Check <br /> may be used for secondary purposes Privacy Law sl 1 m <br /> I. Application Information-Please Print ALL Information State PI I.D.Number <br /> C a3 <br /> Property Owner's Name Parcel Number <br /> ono- 3oa- oa- 1 <br /> Property Owner's Mailing Address Property Location <br /> lq4o CCC IZD- iti 1A:S Z TJO N.R <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> DAl,I tjlA l2j Wt. SM50 X94-7 Zq 4 t c-�... <br /> V, CCT <br /> U.Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms ��//V�� ❑Village <br /> mPL <br /> Public/Com <br /> ercial-Describe Use 2' ext 00465 ownship PMAKM <br /> ❑State Owned Nearest Road <br /> et <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. I New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem I Tank Only Existing System <br /> B. ❑ 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)r Non-Pressurised In-Groin 210 Mound 47 11 Sand Filter 50❑ Constructed Wetland I <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Lite <br /> 45❑ At-Glade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.DispersaMeatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Ram1Gals./Days/Sq.Ft.) (Mindlnch) Elevation <br /> q - S q�. <br /> 00 /8100 /goo q9 .- <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks C <br /> Septic or Holding Tank o = 2�O 3 ,$kA W <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> Plumber's Address(Street,City.State,Zip Code) <br /> 27 7 (Po 4 315 UWSTEX �54$ 3 <br /> VJIL Coun /De artment Use <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Grouadwya�7rer� Date Issued Issu' cut Signature(No Stamps) <br /> Surcharge Fee) �oo (J(J = <br /> ❑ owner Given Initial Adverse � I <br /> Determination <br /> IR.Conditions of Approval/Reasons for Disapproval <br /> OCT 24 2M3I <br /> 3URNE7 7 <br /> Attach complete plans(to the County only)for the system en paper not less than 8 t Y ittrfyit e <br /> l T <br /> SBD-6398 (R. 05101) ICV(j <br />