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aa=YsolabuttatngsUtvision County Qu r h <br /> VIsconsin 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,WI 53707-7162 Site Address <br /> Department of commerce 3!9 Nw 3 <br /> Sanitary Permit Application Samtuy Permit"ter ms� <br /> In accord with Comm 93.21,Wis.Adm.Code,personal information you provide 3 <br /> may be used for secondary Priv Law. 15. 11 m) ❑ Check if Revision <br /> I. Application Information-Please Print AB Informatioa -* a7,/89 Sate Plan I.D. Number I CQ <br /> ( Q <br /> Property Owner's Name <br /> / 1 <br /> Parcel Number <br /> M rk Forsf>:r 301— aptf O�IOt> <br /> Property Owner's Mailie(t Addrem <br /> Property Location <br /> P 6 C30X ! NWA NUIu;S q Y/ N,R IS— E <br /> City,Sate Zip Code Phone Number Lot Number Block Number <br /> &4VT <br /> Subdivision Name CSM Number <br /> trifffewn Wis. SS'SS'8 7)s'-9t).S- 3188 33 fickeS <br /> U.Type of Building(check all that apply) <br /> 1 or 2 Family Dwelling-Number of Bedrooms <br /> 3 ❑City <br /> ❑Village <br /> ❑PubliclCotpmeroial-Describe Use <br /> ❑Stam Owned ®Township SWISS <br /> Nearest Road <br /> yw 3S <br /> M.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line if applicable) <br /> A. 1 R New 2 ❑ Re lacetnent For county use <br /> P System 3 ❑ Replacement of 6 ❑ Addition to <br /> Systenr T� E 'Ex:mm <br /> B, Permit Number <br /> Check if Sanitary Permit Previously Issued ,I „ I `47o DareJIswed <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 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.D' etsa"reatment 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 /> 415'0 (043 6�f8 � . 7 � — 9q. 7 1S• 7 <br /> VI.Tank Info Capacity in i To Number Manufacturer Prefab Sire Steel I Fiber i Plastic <br /> Gallons Gallons of Tanks Concrete Constructed I Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank �BDO _ IOOD N <br /> OYat/lSCO- .0 <br /> Dasiog Chamber <br /> I I i <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 Numbar <br /> ���oey ffo px�l✓s � >� }f'�.--- ' 2'zS$ S I ' �1S- �l 6- 4rS7 <br /> Plumber's Address(Street,City, State, Zip Code) <br /> 277 (o0 4-vv:y 35 (,,l�ssT lz lrll 4593 <br /> NVVI. County/Department Use Onix <br /> kppr <br /> oved El Disapproved Sanitary Permit Fee rincludes Groundwater Date Issued Issuing. ant Signature i Nc Samos) <br /> Surcharge Fee) <br /> j ❑ Owner Given Initial Adverse <br /> Determination �v✓ ' `''" �/ I r r t <br /> LY. Conditions of Approval/Reasons for Disapproval <br /> e� *4)) <br /> Attach complete plain(tn the County only)for the rym neon paper not less than al/2 x 11 inchra in six SBD-6398 (R. 05/01) �ONf %, <br />