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Safety and Buildings Division Camey <br /> NVIsconsin <br /> 201 W. Washington Ave.,P.O.Boz 7162 Mattison,WI 53707 -7162 Site Addr6ts <br /> De artment of Commerce <br /> Sanitary Permit Application Sandary Permit Number <br /> In accord with Comm 93.21,Vis.Adm.Code,personal information you provide ❑ check if Revision �3 U JJJ <br /> may be used for secondarys Priv Law,s15. 1 <br /> I. Application Information-Please Print All InformationState Pian I.D.Number <br /> a 0977.2 ` <br /> Property Owner's Name Parcel Number-qmffI <br /> til fw y 01 JSQ <br /> Property Ownces Mailing,Address Property Location / <br /> :9" I-1s -CAXdSOtj R� - SE 'A Eu•S24 T R �/N Vs <br /> City,State Zip Cowie Phone Number Lot Number Block Number <br /> S I RElJ / W $� U72 Subdivision Name CSM Number <br /> II.Type of Building(check all that apply) (` / ❑City <br /> or 2 Family Dwelling-Number of Bedrooms 3 ❑Village <br /> ❑Public/Commercial-Describe Use owmhiPDAA11CO <br /> ❑State Owned Neatest Road <br /> ToHN ffla5otj <br /> III.Type of Permit: (Check only one box online A(numbering scheme for internal tae). Complete tine B if applicable) <br /> A. 1 ew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> stem Tank Only stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that appiY)(nu .1h 1 g scheme is for internal tae) <br /> 44 ❑ Non-Pressurized In-Ground 21%Mound 47❑Sand Filter 50❑ Constructed Welland <br /> 22❑ Pressurized In-Grotmd 41 ❑ Holding Tank 48❑Single Pass 51❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.DtMsWffreatment 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 /> Oso 6 5v4 r S9 -f /00-/(0 /02 . / 6 <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 Taub <br /> Septic or Holding Tank 1,000 _ <br /> Dosing Chamber boo <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for hurtallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> rev �s 22-58 s ��= g66- MS? <br /> Plumber's Address(street.City.State,Zip code) <br /> 27 7 (oo 'K U63sTMS 3 <br /> VIII <br /> ounty/De artment Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued (No s) <br /> Surcharge Fee) yj <br /> ❑ Owner Given Initial Adverse <br /> Determination `f{' •/v v`J / r` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 6 i <br /> B�RNEr � <br /> � <br /> 2 p� UNTY <br /> Attach complete plea(to the County a*)for tae system of paper not less that SMz 11 loch->a,lu <br /> SBD-6398 (R. 05101) <br />