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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 <br /> Ivisconsin Madison, WI 53707 -7162 Site Address <br /> De artment of Commerce <br /> Sanitary er, iumber <br /> Sanitary Permit Applicationp/ 7t <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check'if Revise <br /> may be used for secondary purposes Privacy Law,s15. 1 m <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Props Owners Namer Parcel Number <br /> r p 5 e_6► n! t-1'Ar 03,;?-9105-Q-70Q <br /> Property Owner's Mailing Address Property Location �/ <br /> g,f- .2 � % %;S T/ N,R E <br /> City,Stare Zip Code Phone Number Lot Number Block Number <br /> £ubdwisian Name P /}' CSNrWuurtiber <br /> 4) �/.2� �S - 77- 37 h5 c/`eS <br /> II.Type of Building(check all that apply) ❑City <br /> Y.`1 or 2 Family Dwelling-Number of Bedrooms ❑village <br /> ❑Public/Commercial-Describe Use "�� wnship �,�/ j <br /> ❑State Owned Nearest Road n� <br /> �r K <br /> 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 =PenmtPreviously <br /> 3 ❑ Replacernent of 6 ❑ Addition to <br /> SystemTank OnlyExis' S stem <br /> B. ❑ Cued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> ";�-Non-Pressurized In-Ground 210 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❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design FloXTmik <br /> l Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> q Yj� �S- 77 <br /> VI.Tankcity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> llons Gallons of Tanks Concrete Constructed Glass <br /> ExistingTanl:aSeptic or Ho - OQ(� 0rce e,5 C U <br /> Dosing Cha <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name( ' t) Plumber'ss Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip ode) <br /> //^e "L) 4JE 5W 72- <br /> VIII. county/ eartment Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Age t Si o Stamps) <br /> pproved ❑ Disapproved Surcharge Fee4 <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County owy)for the system on paper not less tban 81/2 x 11 inches in adze <br /> SBD-6398 (R. 05101) <br />