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Safety and Buildings Division County <br /> W- 201 W <br /> AN W. Washington Ave., P.O. Box 7162 Quvrt eft <br /> `wisconsin Madison, WI 53707 -7162 Sire Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number --In accord with Comm 83.21,Wis. Adm. Code, personal information you provide <br /> Check if Revision <br /> may be used for secondary purposes Privacy LAL� <br /> 150404m) ❑ /.� J/ n ) <br /> I. Application Information-Please Print All Information Sate Plan I.D. Number— ?` <br /> * d <br /> Property Owner's Name Parcel Number <br /> 110 01 Gt !'r Ootlr 4(17 OJ _'" <br /> Property Owner's Mailing Address Property Location.7Q v I*- T-� <br /> /6 5 7S /8O +h Sr. E N 'A:S 17 T 4'O N, R /41 E . <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> fi/�fst//nSS !9l N. SS033 6S/-437-lad9 <br /> II. Type of Building(check all that apply) [)city <br /> Lr I or'_Family Dwelling-Number of Bedrooms ❑Village <br /> ❑ Pubitc/Commercial-Describe Use <br /> Township ..Fro-e7` _ <br /> ❑ State Owned Nearest Road <br /> OCIS'A^"e— Or <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. I New 2 ❑ Replacement System 3 ❑ Repiacement of 6 ❑ Addition to For County use <br /> Sstem I I Taat Only I Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal Ilse) <br /> 44 Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑ Drip Line <br /> 45❑ At-Grade 46 C Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dispersal/Treatment Area Information: <br /> Design blow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Raze System Elevation . Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 300 600 60o '�Fc. 7 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Exis" <br /> Tanks Tanks _ <br /> Septic nr Holding Tank COQ �OQ -S/Gay w <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prnt) Plumber's Signature - MP/MPRS Number Business Phone Number <br /> 6"R,v - <br /> lumber's Address(Street,City,Stare, Zip'Code) <br /> 2.-77 &0 /4w 35 gssrM �4$ 3 <br /> VIU. Count /De artment Use Chfily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Is s mg gent Sign (No Sampsl <br /> Surcharge Fee) �{ ( t 6A <br /> ❑ Owner Given Initial Adverse .7f ,22j� <br /> Demrminarion `�f t/ ri J <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 0101) <br />