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lVisconsin <br /> Safety and Buildings Division City <br /> 201 W.Washington Ave.,P.O.Box 7162 gr <br /> Madison,WI 53707-7162 Site AddYess <br /> De artment of Commerce $g/ <br /> Sanitary Permit Application Sanitary Pe�rmit2Number Cod <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide �- '`-' -7437 / <br /> may be used for secondarypurposes PrivacyLaw,s15. 1 m) 11 Check if Revision <br /> I. Application Information-Please Print AU Information State Plan I.D. Number <br /> C0a <br /> Property Owner's Name Parcel Number <br /> ¢Z 2535 OZ 70& <br /> Property Owner's(Mailing Address r ,' Property Location <br /> f--n n -I <br /> OLI W f'A S F'.A:S 5T N,R <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Qnim ny n-,�1 ►,'I, ✓1 W-o ��5_/$A_Zq?'1 Subdivision Name CSM Number <br /> II.Type of Building(check all that apply) w 1 <br /> ❑Ciry <br /> 1 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑ Public/Commercial-Describe Useownship (� <br /> ❑State Owned Nearest Road <br /> �W�n lk. Rn <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A' eco 2 11 Replacement System 3 ❑ Replacemem of 6 ❑ Addition to For County use <br /> S stem Tank OnlyExisting System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> W.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground �;ff 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 Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> Wo (oCO &0Z 1 .0 '~ �� S l00 ,S <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 1255 <br /> Dosing Chamber ff•.�/�`"' 7h0 <br /> VII.Responsibility Statement- I,the undetsiimed-assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's signature MPlMPRS Number Business Phone Number <br /> :7 . s 71s- 866- 415-7 <br /> lumber's Address(Street.City.State,Zip Code) <br /> 27 7 to o 14,4 35 63 , _'�4467 1 3 <br /> VIII. County/De artment Use Ofily <br /> Approved Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No S ps) <br /> Surcharge ) <br /> ❑ Owner Given Initial Adverse (� <br /> Determination D <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system oa paper not less than 8112 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br />