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` Safety and Buildings Division countwiy <br /> W 201 W. Washington Ave., P.O. Box 7162 z4,An1 <br /> sevnsin Madison, WI 53707—7162 Site Address <br /> Department of Commerce uc— I <br /> �I <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary vurDoses Privacy Law,s15. 1)(m ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan LD.Number �'— <br /> Property Owner's Name <br /> Parcel Number ---'-- <br /> So ,j <br /> Property O/weer"s Mailing Address Property Location —`— <br /> tf li:S T Y0 N.R/G GcJ <br /> City,State =Codephoneumber Lot Number Block Number <br /> :34Subdivision Namer <br /> /U e/` t� ffl�5 <br /> U.Type of Building(check all that apply) <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms <br /> Doty� — <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned -- <br /> Opownship ©1fk <br /> Nearest Road <br /> III.Type��,of Permit: (Check only one box on line A(numbering scheme for.internal tile). Complete line B if applicabba:) <br /> A. 1 Mlilew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank Ord Existin S stem <br /> B. 13 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 /> 44XNon-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Welland <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) Elevation <br /> 3DB y�y y 5-d <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sieel Fiber Pl;;;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 7s- e--. <br /> 7S0 <br /> Dosing Chamber 6-5O <br /> j� <br /> VII• Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plus. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> Plumber's Address(Street"City,State,zip Code) <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Age nature(N n ps) <br /> Surcharge Fee) <br /> Cl Owner Given InitialAdverse � ��j� t <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> APR A 2005 <br /> COl1N_LY <br /> Attach complete plans(to the County Doty)for the system an paper not less than 8112 x BURNETT ZONING 11 inches to size 7Ott 1NG <br /> SBD-6398 (R. 05/01) <br />