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Safety and Buildings utvlslon county <br /> 201 W. Washington Ave.,P.O.Box 7162 6et,rn e-h'- <br /> .iseonsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce 47374 SfoneCo0c 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 �J� O�3 <br /> may be used for second purposes PrivacyLaw,s15. 1)(m I <br /> I. Application Information-Please Print All Infop6ation State Plan I.D.Number <br /> Lk n 0 aq 36`3 <br /> Property Owner's Name Parcel Number <br /> Re&6'e- F•nn e D)d - 4333 -64 4100 <br /> Property Owner's Mailing Address Property Location 60V,L, ` a_ <br /> ) 3d.4 d. lake Stiv rt'_ %• t'A:S 33 T q0 N.R 19 <br /> City,State Zip Code Phone Number Lot amber Block Number <br /> Subdivision Name CSM Numbe <br /> S rin fi2/� ,12 . 4 V 7 CSm V,,1 P a yA-fF Q0 <br /> 1P <br /> II.Type of Building(check all that apply) ❑City _ W <br /> 21 or 2 Family Dwelling-Number of Bedrooms 07` ❑Village _ <br /> ❑Public/Commercial-Describe Use XTownship ch Blot h l tel-' <br /> ❑State Owned Nearest Road <br /> s./an e Gate <br /> III.TypeofPermit: (Check only one box on line A(numbering scheme for.Internal use). Complete line B if applicable) <br /> A. I xy New 2 1-I Replacement System 3 ❑ Replacement of 60 to For County use <br /> S stem Tank Onl Existio S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Petri[Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,431rbNon-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. Dis ersaVTreatment 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.) (MinAnch) Elevation <br /> 3 0o Go0 ,, 4O S` — 51qs s7 a <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber PI; ;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 7Si7 - - 44,2 <br /> 750 <br /> Dosing Chamber 00 -moo <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plauss. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> Rielc f/a lc,.rs 2o�L�lo® � dd��S/ 7/s- e616 iis <br /> Plumber's Address(Street,City,State.Zip Code) <br /> eL 7 7A Hwy 3s l,</ebsfr✓ Gt/r -rf 5�'IY <br /> VII . Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing en igmture 11 ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse J� q p/be� <br /> Determination �f C✓ I <br /> I7C. Conditions of ApprovaLfReasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 51/2 x 11 inches is size <br /> SBD-6398 (R. 05/01) <br />