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7 Safety and buildings urvision county <br /> 201 W. Washington Ave., P.O. Boa 7162 1At-n -e7f- <br /> `�scons/n Madison, WI 53707-7162 Site Address <br /> Department of Commerce InA1,/ <br /> Sanitary Permit Application Sanitary Permit Number - a <br /> In accord with Comm 83.21•Wis.Adm.Code,personal information you provide T�O / �a <br /> ma be used for second purposes PrivacyLaw,s S. 1Xm Check if Revision J / <br /> I. Application Information-Please Print All Information O Sum Plan LD.Number <br /> �_] <br /> Property Owner's Name Parcel Number <br /> �Gic. rf33a vGrn old.- 9js`0- 07_5--00 <br /> Property Owner's Mailing Address Property Location <br /> 175'0 01AA4 t. S. u/ u u;S /0 r "r10N.R/s <br /> City,Sam Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name n-' I CSM Numbs <br /> G/ear Ga ke w� S'70os 7/•S-.63-dd9A be fL Add,-{-oV, V, <br /> IL Type of Building(check all that apply) Dory <br /> S 1 or 2 Family Dwelling-Number of Bedrooms (]Village <br /> ❑Public/Commercial-Describe Use �'rowmhip Jac%s a n <br /> ❑State Owned Neatest Road <br /> me,(.( K�Gf <br /> III.Type of Permit: (Check only one box online A(numbering scheme for internal use). Complete line B if applicablo) <br /> A' 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County tate <br /> S stem Tank Only Existing System <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Dam Issued <br /> IV.Type of Permit: (Check all that apply)(numhering scheme is for internal use) <br /> ,,.vr <br /> 44 k3 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pus 51 ❑Drip Line <br /> 45❑ At-Grade 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 Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) p Elevation <br /> 9� <br /> ySD 6q-? <br /> 64�' 7 — qi•s <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber PI. aie <br /> Gallom Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tv&s _ <br /> Septic or-Holding /000 . /DOO X <br /> Dosing Chamber <br /> VII. Responsibility$talement- t,the undersigned,assume responsibility for installation or the POWTS shown on the attached pL.w. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> /tic% �/o [/r-5 CAI�+a�rrr p(a( fP-fI 7/S- r"e, - 4//S 7 <br /> Plumber's Address(Street,City,Sum,Zip Code) <br /> .1776D f/t... 3S (f/¢(ys�^r wl jr-if&•93 <br /> 1!!:j <br /> e❑ Disapproved Sanitary Permit Fee(includes Groundwater Dam Issued Issuinggem Signature(No Smv ps) <br /> Surcharge Fee) If ��I CU l a,�� <br /> ❑ Owner Given Initial Adverse �4"!' V <br /> Determination <br /> IX. Conditions of Approval/Reasons ror Disapproval <br /> Attach complete plant(to the Cauuiy only)for the system an paper na less than 3112 x 11 inches in size <br /> S13D-6398 (R. 05/01) <br />