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Safety and Bwmmgs utvision county <br /> an#RAF201 W. Washington Ave.,P.O. Box 7162 814,rA to <br /> W isconsin Madison,WI 53707-7162 Site Address 3875 <br /> Department of Commerce I (fo & A <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> ma used /Vy 127 <br /> be for second Purposes Privacy Law, 5. 1)(m <br /> I. Application Information-Please Print All Information State Plan I.D.Number r <br /> Property Owner's Name Parcel Number .� <br /> -�<J(76tWn /floucek — —Q_ 1-lID �y <br /> Property Owner's Mailing Address Property London GOV'-t, (!J <br /> ,?(am /3/st u'e,s u u:S ab T yD N R it <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Numbe <br /> SAlrst e rnN. Ss �7.5' CS M tl 1 <br /> r11..Type o Building(check all that apply) ❑City <br /> ,m 1 or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village <br /> ❑Public/Commercial-Describe Use Orownship sf.?e 'Sprl <br /> ❑State Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B if applic tbh:) <br /> A. 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Penn it Number Date Issued <br /> I44 NV�pe of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> on-pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <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 Area Sod Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min.flnch) Elevation <br /> , _ 7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber PI; otic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Enuring <br /> Tattkf Tanks <br /> Septic or Holding Tank �Q - 8�0 2 ...�,�-� e✓ <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plim. <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phon:Number <br /> Plumber's Address(Street,City,Sure.Zip Code) <br /> 7760 f/ 3s uJe6s7 er r✓� S'S4 1� <br /> VIII Count fDe artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued/ Issuingi <br /> Signa a(No Stan ps) <br /> Surcharge Fee) ,r � /D� /21�rf-6 <br /> ❑ Owner Given Initial Adverse f� 5 C/r <br /> Detemnhudon <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Artach complete plans(to the County only)for the system on paper non less than 8112 z l l inches In size <br /> SBD-6398 (R. 05/01) <br />