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Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 .941" Ctt- _ <br /> ` Madison, WI 53707 -7162 Site Address <br /> Visconsin <br /> Denartment of Commerce <br /> Sanitary Permit Application Sanitary Permit Number ''I1 r� <br /> in accord with Comm 83.21, Wis. Adm. Code, personal information you provide El Check if Revision 1 --y1�03 � <br /> may be used for seconds u ses Privacy Law, s15.040)(m) <br /> I. Application Information-Please Print All Information Sate Pian I.D. Number n <br /> Property Owner's Name Parcel Number <br /> GerQloetHe Schou C 63`4-- tcroLvI 4:"A00 <br /> Property Owner's Mailing Address Property Location <br /> w <br /> //0(,q 11.V4 y8' 1""% Sw S olot T37 N, R JF <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSNI Number <br /> H.Type of Building(check all that apply) [)city <br /> Q.1 or'-Family Dwelling-Number of Bedrooms 3 ❑Village <br /> ❑ Public!Conunercial-Describe Use Atownship <br /> ❑State Owned Nearest Road <br /> N <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 r Newp P For County use <br /> ..�Replacement System 3 ❑ Re iacement of 6 ❑ Addition to <br /> Sys em Tank Onlv I Existing Svstem <br /> B• L-1 Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply) scheme is for internal use) <br /> 44 CI Non-Pressurized In-Ground 24KMound 47❑ Sand Filter 50❑ Constructed Wedand <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 Firal Grade <br /> Required Proposed Rate(Gals./DaysiSq.Ft.) (Min.iinch) Elevation <br /> `-ISD 5�s-v S0 e4 `r — 97. 0 7 917.at <br /> VI.Tank Info Capacity in Total Number Manufacmrer 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 Chambcr /wo <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 /> -4AR-P �r/S zZS$sl 7�S- g66- 4157 <br /> Plumber's Address(Street,City,State, Ztp'Code) <br /> 277 (oo few 35 LABSTMX48 3 <br /> VIII. county/ eartment Use Ofill <br /> Approved 11 Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ge Signamr ( u Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse \ % I (n <br /> A06�0 <br /> Determination YC <br /> IX. Conditions of Approval/Reasons for Disapproval /ti 7r:7-i 77 7�)AUG 1 5 20 <br /> Attach complete plana(to the County only)for the system on paper not less thankf2 x 11 inches in sae <br /> !3URNETT COUNTY <br /> SBD-6398 (R. 05101) ZONING <br />