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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 Af <br /> lvsconsin Madison,WI 53707 -7162 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Permit Number Check if evision 7js 6 <br /> �� <br /> / <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 4`- 7(/6 <br /> may be used for secondarypurposes PrivacyLaw,s15. i)m ❑ <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> Cory t-- 02141 90 5 0/ /00 <br /> Property Owner's Mailing Address Property Location <br /> 90-1 SEN 41L k !6:S 1z T 3c/ N.R /'j E <br /> City,State Zip Code Phone Number Lot Nurr Block Number <br /> Subdivision Name CSM Number <br /> ( N, SSo 11 /Z Bel 3'76> L. Svc <br /> II.Type of Building(check all that apply) ❑City <br /> JZ 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Villa e <br /> g <br /> ❑Public/Commercial-Describe Use wwnship <br /> ❑State Owned Nearest lo <br /> a <br /> see yiv. <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. I QF New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I I Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issu <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal ase) <br /> 44 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 5o❑ Constructed Wet and <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) ^#'t Elevation <br /> 613 tP1/6? • 7 — N1 W,15-,,5- <br /> �3•D <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Construe d Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank / CJD ✓q /UOo w E4CO x <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 /> 2 Z5S s I I I - 46- 4157 <br /> humbei s Address(Street,City,State,Zip Code) <br /> 2.77 (o0 14w 35 £B , �400 LIS <br /> VIII. Count /De artment Use <br /> roved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued IssuingAgent Signature(N Stamps) <br /> Surcharge Fee) <br /> 11 Owner Given Initial Adverse Jho ral�7 <br /> Determination lJ l tr <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 />