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Safety and Buildings Vivision county <br /> Wk 201 W. Washington Ave., P.O. Box 7162 {3 urn -e � <br /> I sevnsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce 'Sob rare -5/7aW Ur. <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide C3 Check if Revision ��/��4) ` <br /> may be used for second purposes PrivacyLaw,s15. 1)(m -7U✓ tv yJ <br /> I. Application Information-Please Print All Information 01/1, <br /> S� State Plan I.D.Number <br /> -f A <br /> Property Owner's Name Parcel Number <br /> Ph" l & 3j - `7,A 3D—dy1fO0 <br /> Property Owner's Mailing Address Property Location <br /> i�av kar ; Lh '2 u;S 7T 4/N,R/3 E <br /> City.State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Numbs <br /> New 3r, titer lY/p/, Ss`/it 6s-/- <br /> R.Type of Building(check all that apply) 3 ❑City <br /> Q 1 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑PubliclCommercial-Describe Use 49Township `wiS,s <br /> ❑State Owned Nearest Road <br /> .sh a w /fir <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B if applicable) <br /> A. 1 ❑ New 2 1?Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> -system Tank Onl Existio S stem <br /> B. ❑ Check if Sanitary Permit Previously issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Q Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Welland <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. Dis ersal/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.nnch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber Pl: ;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> Existing <br /> Fanks Tanks <br /> Septic or Holding Tank /0400 <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached phins. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> 8G e,-- Y�S> <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �77 G O /e�w y 3� W�bs�,°✓ u✓-����g3 <br /> VIII. County/De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A t gnatu Suati ps) <br /> Surcharge Fee) /, <br /> 11Owner Given Initial Adverse 7sS/f' 02_50�� O �1 ' <br /> Determination <br /> IX. Conditions of Approval/Reasoos for Disapproval <br /> Attach complete plasm(to the County only)For the system on paper not less than 81/2 s 11 inches in size <br /> SBD-6398 (R. 05/01) <br />