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Safety and Buildings UIVISIdn Lounty <br /> /� „` 201 W. Washington Ave., P.O. Boz 7162 Entree <br /> ` iscvnsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce flu uSf7en <br /> Sanitary Permit Application Sanitary Petmit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ma �g / <br /> be used for second scs Privacy Law,slS. iXm C1Check if Revision <br /> I. Application Information-Please Print All ormatio 6 State Plan I.D. Number <br /> Property Owner's Name �` /� � /V <br /> Parol Number <br /> ),Plirl weave✓ 00t8 Y//`J 03 :a/o <br /> Property Owxr's Mailing Address Property Lacadon <br /> 8/0 Co fly y vE u A ' u;s /'I T 4io N.R/v # <br /> City,Sum Zip Code Phone Number Lot Number Bleck Num r <br /> v in V. l-0{- 5 <br /> Subdivision Name CSM Numbe <br /> DQ <br /> II e.Asfe� wL sy89? 7/S- (3S- 7rl4P gmV. f a35 p <br /> Type of Building(check all that apply) <br /> Doty <br /> EU I or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑Public/Commercial-Describe Use — <br /> Sown" <br /> is <br /> C1 Suite Owned 'at <br /> Ed <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B if applicablt:) <br /> A. <br /> IN New 2 ❑ Replacement System 3 13 Replacement of 6 ❑ Addition to For Cauntyuse <br /> System Tank ON Ezfstio S <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dam Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 21TMound 47❑ Sand Filter <br /> 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pus 51 ❑Drip Lim: <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dir ersaUTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Disposal Ma Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rarc(Gals./Days/Sq.Ft.) (Min./Ittch) Elevation <br /> �/so � <br /> VI.Tank Inco g <br /> ty N Total Number Manufacturer Prefab Site Sit Fiber Ph ale <br /> ns Gallons of Tanks Concrete Constructed Glass <br /> Eaiuing <br /> Tanks <br /> Septic er Holding Tank <br /> i000Dosing Chamber MVU. Responsibility S - 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached pL,ns. <br /> Plumber's Name(Prim) Plumbei s Signature MP/MPRS Number Bus <br /> Plumber's <br /> Plumber's-Ad <br /> iness Phon:Number <br /> R ffa E,�r c�l..� s8s1 lis- 86/v-suis-] <br /> is(Street,City,Sure,Zip Code) <br /> X7760 /fie,._ 3.s— .C,t�e6s�r.� /,r�.<JTf'693 <br /> . Count fDe artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued [swing c igmmrc m'pt) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach compine ptam 00 1119 County only)rot the srttem en paper eat less then 81/2 sit Inches io rile <br /> SBD-6398 (R. 05/01) <br />