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201 W. Washington Ave.,P.O. Hox62� r <br /> iseonsin Madison. Wl 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Number <br /> Sanitary Permit Application P "�' �3�0�� I,� <br /> In accord with Comm 83.21.Wis.Adm.Code,personal information you provide <br /> to be used for secondarys Priv Law.sly. I)m) ❑ Check if Revision t (� <br /> I. Application Information-Please Print All Information , State Plan I.D. Number U 1 <br /> Property Owner's Name <br /> Parcel Number <br /> Ad 0G-- 44YO - 3)- too <br /> Prope Owner'l Mailing Address <br /> Property Location <br /> 'R SI:S T N.RI� <br /> City,Stam Zip Cade Phone Number Lot Numbe Black Number <br /> bo 301 <br /> Subdivisi CSM Number <br /> f/ 04N 'u-�1f�5 7 17162249L J//d/ rte( j(i lqcw, V. V. <br /> II.Type of Wuilding(check all that apply) Clary <br /> 1 or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village :. <br /> ❑Public/Commercial-Describe Use ownshi N <br /> P <br /> ❑Slate Owned N i <br /> M.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 New 2 11 Replacement System 3 Replaceneause <br /> stem I Tank OnlyE ' S stem I <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> 1V.Type of Permit: (Check all that apply)(ntrmbering scheme is for interval use) <br /> 44 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22 C1 Pmessurized Cut-Gtnntd 410Holding Tank 46❑ Single Pass 51 C1 Drip Lia i <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 Ram(Gals./Days/Sq.Ft) (Min./Inch) I Elevation <br /> �S� X11,3 6 y� • -7 _ qZ.S <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber ! Plastic j <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Dosing Clamber <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 /> «ffioev r/s814= LzZS$S 7l <br /> Number's Address(Street.City,Stare,Zip Code) I 46— 41S7 <br /> 2.7-7 &0 144 35 66 2-051-3 <br /> VIII. County/Department Use OAIV <br /> Approved ElDisapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing at Signatu o Stamps) <br /> Surcharge Fee) /� G <br /> C1 Owner Given Initial Adverse V U.go <br /> Determination v <br /> i <br /> IX. Conditions of ApprovaUReasons for Disapproval y <br /> I <br /> Attach Complete plus(to the County otic)for the system on paper not Ins than 81/2 x 11 lorhn in size ` <br /> SBD-6398 (R. 05101) ON�Nl, Uig <br />