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Is +�y �t w. wasntngtonAve., P.O. Box 7162 5al'17 e� � <br /> c resin Madison, WI 53707 - 7162 �� <br /> Oeoartment of Commerce i s"`Andress <br /> 1 Sanitary Permit Applicationa a <br /> $atutary Permit Number <br /> In accord with Comm 83.21,Wis. Adm. Code• pers <br /> roan be for <br /> oml information you provide <br /> used Secoses Privacy Law,si5.04(11(ml ❑ Chrk if Revision <br /> I. Application Information-Please Print At Information <br /> S-- <br /> ner Plan I.�. Yumoer 1 <br /> Property Ows Name <br /> Parse!Number <br /> ro �`rySnow 04- 2,t75-- &7140 <br /> Pperty Owner's Mailing Address � <br /> �Oif" sg ProPettl'Location <br /> City.State Zip Cade K -A:S ot7 T 40 N,R /X- <br /> Phone Number Lot Nutnber <br /> /5_9 Block Yu[aL•er <br /> I <br /> FC /� Subdivision Name <br /> ee n I ` CSM Number <br /> I ION. 563 9 3d -ctG8-63x3 �Sksc— UED. E� V, U <br /> II.Type of wilding(check all that apply) <br /> G].I or 2 Family Dwelling-Number of Bedrooms 3 ❑City <br /> ❑Public/Commercial-Describe Use ❑Vt7lage <br /> ------------- <br /> ❑State owned ®Township Ja<l<s o/1 I <br /> INearest Road <br /> M.Type of Permit: (Check only one box online A(ntnmbet'ttng scheme for int <br /> ' E q �pS h/es�` ��• <br /> A. ernal ase). Complete Line B if applicable) <br /> 110 New 2 ❑ Replacement System 3 ❑ Replacement of C1Far Co <br /> stem Tank ON 6 Addition to qty ax <br /> B ❑ Check if SamPermit Number S stem <br /> nary Permit Prevrotuly Issued Date Issued <br /> IV.Type of Permit' (Check all that apply)(nr�bering scheme is for internal rue) <br /> 44&Non-Pressurized In-Ground 210 Mound ❑ Sand Filter22 Q Pressurized la-Gromtd 41 ❑ Holdi[tg rank 4 477 Q S' 50❑ Constructed Wetland <br /> 45❑ At-Grade mgle Pass 51❑Drip Line <br /> V.D' <br /> 46 Q Aerobic T[umtent Unit 49❑Reciiadating C130 Other <br /> anent Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Sod Application <br /> Required Proposed <br /> Percolation Rate System Elevation Final Glade <br /> > Rare(GalsJDays/Sq.Ft.) (Min,/Incb) <br /> `I,�0 700 �0 o Mevation <br /> 9y. <br /> VI.Tank Info Capacity in Total Number <br /> GallonsGallotu of Tanks Mawfacttuer Prefab Sire Steel Fiber I <br /> New F^.:^ <br /> St I Concrete Consaucred I Glass Plastic <br /> Tanks Tanks <br /> Septic or Holding Tank /b 00 - �DOO i <br /> Dosing C3amber 604 p� I I I <br /> VII.Responsibility Statement- I,the undersi <br /> Plumber's Nam(prim) Vied,2m=e responsibility for installation of the POWTS shown on the attached plans. <br /> ( ) Plumber's Sigmature I MPIMPRS Number <br /> Business eZOne Number <br /> 71s Address(s ,✓s Z 25 S.5 7�S g66- Q4S7 <br /> lumbers Address city.stare.Zip code) <br /> 2.77400 <br /> Corm /De artrnent Use Ofily <br /> Approved ❑ Disapproved Sanitary Pemt3 Fee(includes Grotmdwatar <br /> Surcharge Fee) Date Issued issuing. [Signature! ' mos) <br /> ❑ Owner Given Initial Adverse <br /> Detertmmation •� v /s�✓L�Q 1 T <br /> 01) <br /> IX. Conditions of Approval/Reasons for Disapproval J <br /> i <br /> I <br /> Attach complete plana(to the Cama 01117)for the system on <br /> Paper not leu than 812 c Al t11ches i11 tae <br /> SBD-6398 (R. 05101) <br />