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Safety and Buildings Division Countyp —� <br /> ` 20: W. Washington Ave., P.O. Box 7162 8. rn e ft- <br /> isconsin Madison, WI 53707 -7162 Site Address <br /> Department of Commerce 3� OBJ ,� R� <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision 46898� <br /> may be used for seconds purposes PrivacyLaw. s5.044 U(m) <br /> I. Application Information-Please Print All Information /a 'I Stare Plan I.D. Number <br /> (� F VYJ <br /> Property Owner's Name Parcel Number <br /> 03d. - sols--()3-/OD <br /> Property Owner's Mailing Address Property Location OV`>`-•(-OT a <br /> .574/6.j- <z- day Ale. . 4. 'A: S /Ir T 5e/ N. R/S- <br /> City. <br /> S City,Stare Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> Su Brio✓ Lt/ S-1/ 880 r!/S- 39d- `/syr <br /> R.Type of Building(check all that apply) <br /> K <br /> 77 ❑City <br /> p I or 2 Family Dwelling -Number of Bedrooms o` <br /> ❑Village _ <br /> ❑ Pubiic.'Commercial -Describe Use �7'ownship $W/SS <br /> L1 State Owned '— <br /> Nearest Road <br /> Al UesS LA IN <br /> IR. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. y <br /> 1 � New 2 �i Replacement System 3 � Repiacemem of 6 � Addition to For County use <br /> S stem Tank Got Existin Svstcm <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,R Nan-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50 JJ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48 U Single Pass Sl ❑ Drip Line <br /> 45 L1 At-Grade 46❑Aerobic Treatment Unit 49 L1 Recirculating JO 0 Other <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal.Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Acquired Proposed Rate(Gals./Days/Sq.Ft.) (Slim./Inch) 410pe,l -JA cs Elevaticn <br /> 300 4119 yid . 7 �pwe� 9i. F <br /> VI.Tank Info Capacity in I 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 <br /> Dosing Chamber S-OQ S o0 <br /> VII. Responsibility Statement- I,the undersigned, assume ruponsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbei s Signature MP/MFRS Number Business Phone Number <br /> ci+Ag /r/S "� "� 77-575 .51 115- S(o6- 41P7 <br /> lumber's Address(Street,City,Stam,Zip Code) <br /> 27 7 (a o j4w 35 1�4-93 <br /> VIII. County/ eartment Use Ofily <br /> ❑ Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) " <br /> Surcharge Fee) <br /> ❑ Owner Given Iridal Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> JUL 2 0 2M <br /> Attach complete plans(to the County only)for the system on paper not Ins than gl/2 x 11 Inches in SMURE�COUNTY <br /> SBD-6398 (R. 05101) ZGNIN+G <br />