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Safety and Buildings Division County <br /> NVISconsin 201 W. Washington Ave.,P.O. Box 7162Madison, WI 53707 -7162 Site Address <br /> Department of Commerce ) <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.2 1.Wis.Adm. Code,personal information you provide <br /> may be used for secondarypurposes PrivacyLaw s15. 1 (m) C1 Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D.Number OQ <br /> Property Owner's Name Parcel Number t (Z <br /> Property Owner's Mailing Address Property Location a— ISI V 1 <br /> 1-23gdo LAMJ� MOD LK YomD 14-SG ,[y:S 27T N, R <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> 54$4n <br /> ,IS_ �$9 -2498 <br /> 11. Type of Building(check all that apply) ❑City <br /> l or 2 Family Dwelling-Number of Bedrooms 3 ❑village <br /> ❑ Pubiie/Commercial-Describe Use 1I'ownship {1/ l(,p,'yv <br /> ❑ State Owned Nearest Road <br /> Cn• Izn <br /> III.Type of Permit: (Check only one box online A (numbering scheme for interna!use Complete line B if applicable) <br /> A For County use <br /> 1 New 2 ❑ Replacement System 3 LJ Replacement of 6 El Addition to <br /> System Tank Only Existinit S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> li <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Non-Pressurized In-Ground 20 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) Elevation <br /> 46u 6�� 609s $ <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> I, <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank ir/i© �- 119190 <br /> Dosing Chamber VV <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 /> c} OQD �n/s z 25S.-51 715- S66- 4 -5-7 <br /> lumber's Address(Street,City,State,Zip Code) <br /> 2-7-7 &0 i4w �K Uia3 <br /> VIII. Count /De artment Use 1 <br /> Sanitary Pe 't Fee(includes Groundwater Date Issued Issuing A nt Sin Stamps) <br /> roved ❑ Disapproved Surcharg£F ) /^q.( ) `9�4 <br /> ❑ Owner Given Initial Adverse "' O t V`�' O <br /> lo <br /> Determination -, <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> _J <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. 05/01) <br />