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Safety and Buildings urvision county <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> O iseonsin Madison,Wi 53707-7162 Site Address <br /> Department of Commerce 14I °Sw;z Ci44LLT IC,t <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision p <br /> ma be used for second ns PrivacyLaw,s15. 1Xm <br /> 1. Application Information-Please Print All Information State Plan Number <br /> Panel Numbberer <br /> Property Owner's Name . ,� 00 <br /> �tnl i RA q} Ktn5 006.2.17,49-0LOO <br /> �P(o <br /> Property Location <br /> Property Owner's Mailing Address LUV& —9 <br /> 11°11 ,,a.a�SS l�Ms0.�tT l�ogd— u: <br /> City,State Zip Code Phone Number Lot Number Bleck:lumber <br /> tt Subdivision Name CSM Numtx <br /> -S 2eA _ Lglt, U)= S`f871 albf!- 2151 <br /> II.Type of Building(check all that apply) ❑City _ <br /> Owl'or 2 Family Dwelling-Number of Bedrooms ❑�Village _ <br /> ❑Public/Commercial-Describe Use �Osownship <br /> ❑State Owned Nearest Road <br /> aJl $ A"X- <br /> 111. <br /> X -III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 11 New 2xReplacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> System Tank Ord Exit' S stem <br /> B. 1 ❑ Chick if Sanitary Permit Previously Issued <br /> Perron[Number Dam Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44XNon-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50 D Constructed Weiland <br /> 22 D Pressurized In-Ground 410 Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45 D At-Grade 46 D Aerobic Trntment Unit 49❑Recirculating 30 D 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 Ram(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> (e00 858 900 r-7 Mo h 9Z •O 95 ,(�-�16aa <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber Ph aic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic n.si�.�- 17.54 12S4 V <br /> Dosing Chamber -IVL,f .154 <br /> VII. Responsibility Statement- 1,the undersigned,ass a responsibility for cost t of the WTS shown on the attached phos. <br /> Plumber's Name(Print) s Signa r P 11 um IS 7l; Business Phone Number <br /> K SEFTnIC & EXCA <br /> PlumOMOWNT- CUNFR <br /> SPOONER, WI 54801 <br /> VUL Coumtvjtj&jbdb1dt4W Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin gc ignamr t'Pt) <br /> 01" Surcharge Fec) 2 r <br /> ❑ Owner Given Initial Adverse7r/TA J 6 <br /> Determination <br /> IX. Conditions of ApprovalfReasons for Disapproval f <br /> MAY 2 5 am <br /> Attach complete plans(to the County only)for the system on paper not Im than 91/2. e COUN� <br /> ZONING <br /> SBD-6398 (R. 05/01) <br />