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Safety and Buildings Division Coon <br /> 14'sconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 4e e Madison,WI 53707 -7162 Site Address <br /> Department of Commerce Sanitary Permit Number <br /> Sanitary Permit Application ?s 29 7 if D 70 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ heck if Revision <br /> may be used for seco uy purposes Privacy Law,sl5.251 in <br /> State Plan I.D.Number <br /> I. Application Information-Please Print All Information 9 a q Q <br /> Parcel Number <br /> Property Owner's Name l/) <br /> r, O� <br /> G Property Location <br /> Property Owner's Mailing Address <br /> 5 tk 'R: T V15 N.R I <br /> N1 <br /> City,State <br /> Zip Code Phone Number Lot Number Block Number �I <br /> e CSM Number <br /> 7-2 239'_� S aof�a <br /> II.Type of Building(check all that apply) ❑City <br /> or 2 Family Dwelling-Number of Bedrooms —� ❑Village <br /> ❑Public/Commercial-Describe Use ownship SG O <br /> Nearest Road <br /> ❑State OwnedLC <br /> C O. Ad <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> ���///,,, ��- For County use <br /> A. 1 ❑ New 2�pr teplacennem System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem / Tank Only Exis' System <br /> T <br /> ed —� <br /> B. Check if Sanitary Permit Previously Issued 971 9� ' <br /> IV.Type of Permit: (Check all that apply)(numberini scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 21%,Mound 47❑ Sand Filter 5o❑ Constructed Wedand <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade <br /> 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final <br /> G <br /> Retptired Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) <br /> Asa /oa,Ar • 0 <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 <br /> Dosing Clamber SO �SD <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Name(Print) <br /> 4. 7 d <br /> Plumber's Address(Street,City.State,ZIP Code) 110, <br /> VIII. Corm /De artment Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing ant Signa r No Stamps) <br /> proved ❑ Disapproved Surcharge Fee <br /> ❑ Owner Given Initial Adverse- 50 <br /> Determination <br /> IX.Conditions of ApprovaUReasons for Disapproval rt✓ <br /> 0C Lt. (tidy C) <br /> „_Yf-�,�►'1 �l`�i7,' t�SlYir/r�, �� <br /> / 10e— <br /> Q � <br /> Attach complete pains(to the County only)for the system on paper not leu then gl/ 111 inches In size <br /> SBD-6398 (R. 05/01) <br />