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Safety de Buildings Division <br /> Sanitary Permit Application 201 W.WashingtanAve. <br /> lseonsln In accord with Comm 83.21,W is.Adm. Code PO Box 7302 <br /> Deoertment of commerce Personal information you provide may be used for aemndary purposes Madison.WI 53707-7302 <br /> [Privacy Law,s.15.04(i)(m)] (Submit completed form to county ifnot <br /> state owned <br /> /� Attach complete lana to the en w oro for the system,on r not less than 8-1/2 x l l inches in size. <br /> �yLU NETT SIM <br /> ZrOYP <br /> 't Numbs Ll Check it 'sioo wtau Plan L D.Number <br /> L Application Information-Please Print all Information IAC26011: <br /> r'topaty caner name Property t <br /> DEf1�t/ .6�Z-- 3�trs5;i—�Cil/=4..S q T WN,w (°irF� <br /> Address Let Number Block Number <br /> S--,/ Fc�' hl�61��,v.�5 Tf'pi� a/�. 3 0 1 <br /> City,State Zip Code Plane Numbs Subdivision Name or CSM Number. /" <br /> 21Li-no ( e-5-1 ) '7";9- goy/ 00*4 Cs». VP3 � <br /> H Type of Building: (check one) . ❑City <br /> 1k 1 or 2 Family Dwelling—No.of Bedrooms:_ ❑VEW <br /> 0 PubliMCommetcial(describe use): )'Town of 1)�j lb?\3 <br /> 0 Slate-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) N�+s Rod <br /> A) 1. New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Ta c Numbeu(scro�� � �� <br /> Tank Only Existing svitent - 141414-a7 -3610 <br /> B) Permit Number Date Lowed <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> $.Noo-pressurized Ie-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized Io-gbound ❑Holding Tank ❑Single Pan ❑Drip Lia <br /> ❑At-grade ❑Aerobic Treatment Unit ❑ Recirculating ❑Other. <br /> V Db rsal/Tmatment Area Information: <br /> L vamp Flow(gpd) 2.13ispersslAxes I 3.DispersalArea 4.Soil Application 5.Percolation Ran 6.System Elevation 7.Foul Grade <br /> Required Proposed Rate(OWday/4 R) (MiNiah) Elevation <br /> ©© 4a9 43s - ,,7 A14 9s-8 98. D <br /> VI Tank Capacity in Total It of Manufaemrer [hefab Site Sleet Fiber- Plastic <br /> Information Gallons Gallons Taroks Con- Con- glass New Existing trete strnctcd <br /> Tanks Tanks ���-� Go�u4� <br /> rl Sn ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I,the tmdtasi ed,assume nsibiii for installation of the POWTS shown on the attached lana. <br /> Phmbees Name(Gran) P Sigosuae(ro stamps) MP/MFRS No. Business Pfaute Number <br /> o ,� ��e, r zr aa��7o 1 7167' 2444- 3soCr <br /> A (Street,City,State,Zip Code) <br /> S - s7—'4-?-L� 12Q 35- <br /> V111 <br /> 5VIII County/Department Use Only <br /> f13Disapproved Sanitary PmnA Fe (Includes pmmdwater Date holing Prue( ) <br /> 1�C1 Approvedvcd C3Owner Given initial Adverse Surcharge Fee) �� <br /> Determination t�U C Lwed%6,3 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br />