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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Boz 7162 <br /> Itseonsin Madison,WI 53707-7162 Site Ad s <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Permit Number/ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide -/a3 7-o9 <br /> may be used for secondary purposes Privacy Law,s15.04(1m ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D.Number Q <br /> Property Owner's Name , Parcel Number <br /> �`/--t23 6/�-3 0 DI�rJ`D <br /> Property Owner's Mailing Address ��7j Property Location �} <br /> 45-3+ lxwf�� 'k 4:S .5 T N,R <br /> City,State Zip Code Phone Number <br /> �f!, Lot Number Block Number <br /> ��}a fOb r�,/ I I g�Q �1S L�_I 1`�qo <br /> Subdivision Name CSM Number <br /> N ll,vt ic.vll IQV A <br /> II.Type of Building(check all that apply) <br /> ❑City <br /> or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village � J,/� <br /> ❑Public/Commercial-Describe Use ownship /V eo <br /> ❑State Owned Nearest <br /> 04 D"NWEW Z2` <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. ew 1 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 Permit Number Date Issued <br /> pe of Permit: (Check all that apply)(ntrmbering scheme is for internal use) <br /> IV.Ty <br /> Non-Pressurized In-Ground 2111 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) (()r 96.S Elevatiw-5- <br /> 27 <br /> qoo /%cc Igo - S �--' °' 97,s- 99'996- <br /> 97� <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 �Q / <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> � v >✓s zz-5S S' ( 715- g66- �S7 <br /> lumber's Address(Street,City,State,Zip Code) <br /> 27 7 (o o few 35 U6OsTM . 2�4$ 3 <br /> Count /De artment Use Ofily <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Approved El Disapproved <br /> Surcharge Fee) , /// i <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 05101) <br />