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Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 �P/lllArlf <br /> VVisconsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce f>NSCool Af <br /> Sanitary Permit Application Sanitary Pe it Nuumbe I <br /> in accord with Comm83.21,Wis.Adm.Code,personal information you provide �`on <br /> m be used for sew s PrivacyLaw,sty. 1)(m ❑ Check i Revision <br /> I. Application Information-Please Print All Information3 a Sam Plan I.D.Number <br /> P Owner's Name Parcel Number <br /> ,r�v;j 1�„ oa�9 �s o6 moo <br /> Property Owner's Mailing Address Property Location <br /> IX 7 ,r 4 'A 'A;S T-O N.R <br /> City,State Zip Code Phone Number Lot tillpilner Block Number <br /> 40 Subdivision Name CSM Number <br /> 7w — 90 vo <br /> 11.Type of Building(check all that apply) ❑City <br /> )eq 1 or 2 Family Dwelling-Number of Bedrooms []Village <br /> ❑Public/Commercial-Describe Use nahip <br /> ❑State Owned tares[Road <br /> Ill.Type of Permit: (Check only one box on line A (numbering scheme for internal use Complete line B if applicable) <br /> A' 1,0 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> system Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dale Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44/❑`IVNon-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 ersaUTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Finan Grade • <br /> Required Proposed Ram(Gals.IDays/Sq.Ft.) (Min.Anch) Elevation <br /> , -7 9c 9�. z <br /> VI.Tank Info Capacity in Tout Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrem Constructed Glass <br /> New Exudng <br /> Tanks Tanks . <br /> ftlic,br Holding Tank k O <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) Plum S' ture MPIMPRS Number Business Phone Number <br /> Plum ' Add s(Street,City,State,Zip ode) <br /> ji � Y leo <br /> 1. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing gen[Signature(No Sumps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse p��w db <br /> Determination <br /> IX.Conditions of Approval/Reasous for Disapproval <br /> Anach complete plans(to the County only)for the tynem on paper not less than$1/2 x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />