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Safety and Buildings Division County <br /> ` y 201 W. Washington Ave., P.O. Box 7162 43u Y✓t 'e <br /> iseonsin Madison,WI 53707 -7162 Site Address 3r) <br /> Department of Commerce 0etr fq�A Rd, <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm. Code, personal information you provide 4 CQ Q Q /419 <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number N <br /> Property Owner's Name Pa umber <br /> 1 J,_gJ.so "i'3_600 (C,07-310 <br /> Tott•l GGIa k-1415 _ <br /> Property Owner's Mailing Address Property Location lia <br /> 3161 I40fti St <br /> 4 4;S IV TZ/O N,R /SE <br /> City,State Zip Code Phone Number Lot Nu t 11hock Number <br /> 30 3/p <br /> Subd vis-ldnrame CSM Number <br /> Pr,o•- Gake <br /> V4 Al. SS37,t �s� -4yS-s�o6 bf 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 i so,-I <br /> ,Township jo_ <br /> ❑State Owned Nearest Road <br /> Uee✓ peo-4 Rd <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. County use <br /> 1.� New 2 El Replacement System 3 ❑ Replacement of 6 [1 Addition to <br /> System Tank Onl Existin S stem <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 use) <br /> 44 lO 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 System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) ,epee 99,. 8 Elevation <br /> Cay (a 9' ^— Idt�er 9R.r 94 5— <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks q <br /> Septic or Holding Tank <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(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> e*»oev /,✓s 1p,r:� 17-zs 0S s r 15- 46- 4+s7 <br /> lumber's Address(Street,City,State,Zip'Code) <br /> 27 7 to o /4vv 35 ER , _�4063 <br /> VIII. County/De artment Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A t 'gnamrer(Nos) <br /> Surcharge Fee) u N- „^ <br /> ❑ Owner Given Initial Adverse r%1 �L-.)l// 2¢ �VK-O4 <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br /> Z <br /> �5 <br />