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ReU Safety and Buildings Uivision t ounty <br /> aw 201 W. Washington Ave., P.O. Box 7162 8"rn'e,iseonsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce 6J.&tt- aea✓ Pass <br /> Sanitary Permit Application Sanitary Permit Number IDQ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision 446 <br /> may be used for secondary purposes Privacy Law 15. 1)(m <br /> I. Application Information-Please Print All Information �y State Plan I.D.Number <br /> Property Owner's Name L7 Parcel Number <br /> A- --t� ok S,ssc h o l d. - <br /> Property Owner's Mailing Address Property Location <br /> s 3 e4 3 S /,'t !�a ;I D,, to u:S IS T Ve N.R ft <br /> City,State Zip Code Photo Number Lot Number Block Number <br /> 39 <br /> SubdivisionName CSM Numbe <br /> RCk'#"Antown y✓)N, SSS/f <br /> II.Type of Building(check all that apply) ❑City _ <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village _ <br /> ❑Public/Commercial-Describe Use •'QTownsh p ,Jwc k se N <br /> ❑State Owned Nearest Road <br /> 6r at` &ecu r lea t5 <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for-internal toe). Complete line B if applicable:) <br /> A' 1�New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> 5 stem Tank Ont ExistingSystem <br /> B. ❑ Check if Sanitary Permit Previously Issued Pernik Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44-5 Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Weiland <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 S stem Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min.flnch) Elevation <br /> SSD 693 Gu >� , 7 9! -7 4Q. 7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sigel Fiber PL• alc <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank �p� - /100 A1,4PWeSe-v <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,asstme responsibility for installation of the POWTS shown ion the attached pls ns. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> Plumber's Address(Street.City,State,Zip Code) <br /> --7 760 Ives, 3S` we6sr e✓ WY Sit-err:5 <br /> 7LIX. <br /> Count /De artment Use Only <br /> proved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ge Signa o Sm'ps) <br /> Surcharge Fee) / ��n <br /> ❑ Owner Given Initial Adverse S0 % II Aq 01 <br /> Detertlination <br /> onditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 111/2 x 11 inches in site <br /> SBD-6398 (R. 05/01) <br /> i <br />