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Safety and Buildings Division county <br /> 201 W. Washington Ave.,P.O.Box 7162 4f <br /> Madison,WI 53707-7162 Sim Address <br /> iseonsin <br /> De artment of Commerce Sanitary Permit Number <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide [I Check if Revision <br /> may be used for secondary purposes.Privacy Law,sl 1 m) State plan I.D.Number <br /> I. Application Information-Please Print All lnforvtation <br /> Parcel Number <br /> Property Owner's Name 1O'I� <br /> <J <br /> e A4 I\J S rwi p©t.ty TACBdon 7 �r <br /> Property Owner's Mailing Address 5r 3 8N,R `O <br /> 110 -5- .J� S S4 !f;S T <br /> City,State <br /> Zip Code Phone Number Lot Num r ock Number <br /> bdty sion Name CSM Number <br /> 44 41,5 G� 5-Vd �G <br /> U.Type of Building(check all that apply) ❑City <br /> K1 or 2 Family Dwelling-Number of Bedrooms ❑Village ,r.. Q <br /> ❑Public/Commercial-Describe Use <br /> ownship !N 00 ^ ✓ e r <br /> Nearest Road <br /> ❑State Owned .20790 <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B V applicable) <br /> A' 1 ❑ New 2Replacemem System 3 ❑ Replacement of 6 El Addition to <br /> For County use <br /> Tank Only Exist'-- <br /> S sum S sum <br /> Permit Number Date Issued <br /> B. 11Check if Sanitary Permit Previously Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Ion-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetlard <br /> 22❑ Pressurized In-Ground <br /> 41[1 Holding Tank 48❑ Single Pass 510 Drip Line <br /> 45❑ At-Grade <br /> 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatment Area Int'ormauQu: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rau System Elevation Elev <br /> Required Proposed Rate(Gals./Days/Sq.Ftationbe <br /> J (Min./Inch) <br /> Manufacturer Prefab Siu Steel Fiber Plastic <br /> VI.Tank Info Capacity Total Number Concrete Constructed Glass <br /> Gallons Gallons of Tanks <br /> New Existing <br /> T Tanks <br /> Septic or Holding Tank _516 <br /> Dosing C <br /> VII.Responsibility Statement- I,the undersigned,assume responsrbIDty for installation of the POWTS shown on Hn tachess pdhpolans.ne utnber <br /> Plumber's Signature IviP/MPRS Number <br /> Plumber's Name(Print Z / <br /> Plumber's Address(Street,City, <br /> State, <br /> Zip Code) <br /> ,g 6,X -S—/ VSri G -j lvZ 5 <br /> VIII. Count /De artment UseOnl m o Sram s) <br /> Sanitary Permit Fee(includes Groundwater Dau Issued Issu <br /> Signa P <br /> Approved ❑ Disapproved Surcharge Fee) n M7 t <br /> ❑ Owner Given initial Adverse <br /> Determination o• <br /> IR. Conditions of Approval/Reasons for Disapproval <br /> pt�k complete plant(to the Cowty only)ror the e7et�ea PaP�tlOt lees thsu Slr2 x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />