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Nvisconsin <br /> Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> Madison, WI 53707 -7162 Site Addr ss � I L <br /> De artment of Commerce UCYI�n11 <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis. Adm. Code, personal information you provide 4 / J <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) _ <br /> ❑ Check if Revision ;O <br /> I. Application Information-Please Print All Information ;L7 O State Plan I.D. Num¢err <br /> Property Owner's Name Parcel Number <br /> o 0Z OZo 431-s OZ <br /> Property wner's Mailing Address Property Location <br /> W 0!4- NUJ %SYu /4:S /3 T 40 N, R f 6i 4/1 <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> m 1i-)� lo/ <br /> S524,7 <br /> r/A"�. h^ �/ Subdivision Name CSM Number <br /> H.Type of Building(check all that apply) J(O l J 10 <br /> []city <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms ❑V Mage <br /> ❑ Public/Commercial-Describe Use Township <br /> El State Owned Nearest Roa � j <br /> �tZson laK� <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 ew 2 11 Replacement System 3 ❑ Replacement of 6 11 Addition to For County useS stem Tank only <br /> Existin S stem <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> i <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for intemal use) <br /> 44 El Non-Pressurized In-Ground 21XMound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22 El Pressurized In-Ground 41 El Holding Tank 48 El Single Pass 51 [1 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 /> 500 'boo 1.0 <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 m _ <br /> Dosing Chamber �;_00 I Sto j <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 /> 17-je-ifAlvi) RDir/s - 22S$ S 7/ S66- 4K-7 <br /> lumber's Address(Street,City,State, Zip Code) <br /> 2.7 7 (o o /4w 35 � <br /> —V;II. CountyDepartment Use Ofily _ <br /> Approved El Disapproved Sanitary Permit Fee includes Groundwater Date Issued Issui�i naturStamps) <br /> Surcharge Fee) A jJ <br /> ❑ Owner Given Initial Adverse � v, Vv <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval Oct <br /> . BURNE ? 8 <br /> Z0�CpVN <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches is size <br /> SBD-6398 (R. 05101) <br />