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Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O.Box 7162 a/fr <br /> iseonsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce 9 13S �rt,� ®p <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide �aAeo( <br /> may be used for secondary purposes Privacy Law,sl5. 1 m ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan LD.Number <br /> Property Owner's Name Parcel Number <br /> jeF` �/� 9jFsa9 -amv G� <br /> Property Owner's Mailing Address Property Location a ` O <br /> City.State Sf Sf;S l T 7r!/ N.R <br /> Zip Code Phone Number Lot Number Block umber <br /> -7/ a -$ -r N <br /> �2 I $� Subdivision NameCSMumber <br /> �/r'R&,AwS AAAOOOy7 <br /> II.Type of Building(check all that apply) miry <br /> or 2 Family Dwelling-Number of Bedrooms <br /> []village <br /> ❑Public/Commercial-Describe Use <br /> ❑Sate Owned ownslvp -54'N <br /> Barest Road <br /> Aw <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 WNew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> stem Tank Oel Existim 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)d 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 Flow(gpd) Dispersal Area Dispersal Arca Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) pf�i Elevation <br /> Asa 6s3 ,� /��, q 9�l 2 <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 /> epni r HoWmgTank / <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plant. <br /> Plumber's Name(Print) Plumber' Si lure MP/MPP RS Number Business Phone Number <br /> Plumber' Address(S et,City,State,Zip e) �> <br /> 7 <br /> VIII. Count /De artment Use Onl <br /> �pproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater D to Is sed Is <br /> Agen S' na re( ps) <br /> 1% <br /> Surcharge Fee) (� _ <br /> ❑ Owner Given Initial Adverse tpv'�J,6�,(� / <br /> Determination <br /> IX. ConditTsXaTv� <br /> ovalfReasonfos r Disapproval 0 Lech <br /> MAY 14 2p02 i <br /> Attach complete plans(to the County only)for the system on paper not less thaMkNgTn r <br /> SBD-6398 (R. 05101) ZONING <br />