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jt& <br /> Safety and Buildings Division County <br /> AN 201 W. Washington Ave., P.O. Box 7162 <br /> v iseonsin Madison, WI 53707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application <br /> Sanitary Permit Number Q <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide <br /> Check if Revision <br /> may be used for secondarypurposes Privacylaw,sl5. 1)(m) <br /> ❑ <br /> I. Application Information-Please Print All Information ab-7 SA-S <br /> State Plan I.D.Number <br /> Property Owner's Name Parcel Number ` <br /> N X-o-¢323-0/- ZO <br /> Property Owner's Mailing Address Property Location <br /> Doo De ti %:S T 40 N,R /6 <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> IW4V yVA/f yA_ / RAI L'S'112 9 1-51 567 Subdivision Name CSM Number <br /> /1/(�Y1/ //rL{ l7/v/V /"'/V 7 fS/ tvJ ✓ /3 <br /> el 99 <br /> H.Type of Building(check all that apply) ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms <br /> []Village � <br /> ❑ Public/Commercial-Describe Useownshi p aAkl 4AAO <br /> ❑State Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. C.New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I I Tank Only Existinq i <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 /> 4LL`1 Non-Pressurized In-Ground 21❑ 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.) (Min5" <br /> Elevation <br /> s qs.g qr 9 <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 <br /> Septic or Holding-Tank /000 IV- 49 , D I_H//�7 60 <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 /> � oev �/s - 2z7 s 7 is- S66- 4►s7 <br /> lumber's Address(Street,City,State,Zip Code) <br /> 2.7_7 &V ARM , S-4-4611-3 <br /> VIII. CountyDepartment Use Ofily <br /> ❑ Approved Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ent S'gnato Stamps) <br /> Surcharge Fee) DO 00 O <br /> ❑ Owner Given Initial Adverse Q <br /> Determination <br /> IX. Conditions of ApprovaUReasonts for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br />