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' Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 Qu 0-r? <br /> Nvisconsin Madison,WI 53707 -7162 Site Address �_I <br /> Department of Commerce _ &p�7i P4 <br /> Sanitary Permit Application Sanitary Permit Number <br /> in accord with Comm 83.21,Wis.Adm.Code, personal information you provide [ICheck if Revision 45394 4 <br /> may be used for secondary PuM2ses Privacy Law,s 5.04(1)(m) <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> Property Owner's Mailing Address Property Location <br /> Sw 'k SE ti;S 7 T 90 N,R 47 w <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> Tihle Paek �—C. (00477 70�- �3d ` dY�'7 LU l I 1: nKC45 <br /> H.Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms []Village <br /> ❑ Public/Commercial-Describe Use ,Township �)te L/C•Ss <br /> ❑State Owned Nearest Road <br /> S6ben Pd. <br /> III. Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 ❑ New 2,R Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I Tank Only Existinz S stem <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,®'Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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 Mow(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 /> 300 yt9 yid <br /> 7 ti�• � ioo. o <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 <br /> Septic or Holding Tank �p p _ <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/MPRS Number Business Phone Number <br /> c"K?p Bbpxlr/S '�` 2ZS$S 1 15- SW 44_S7 <br /> lumbei s Address(Street,City.State,Zip Code) <br /> 27.7100 /4w-f 35 , _�4063 <br /> V . Count /De artment Use Ofily <br /> Approved 11 Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing a Signa o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse a5V J �-�0t <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plane(to the County only)for the system on paper not Im than 8112 x 11{aches in size <br /> Z85, <br /> SBD-6398 (R. 05101) <br />