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NVisconsin 201 W.Washington Ave..P.O. Boz 7162 w y &r n e ty- <br /> Madison,WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Santtary Permit Naber I� <br /> In accord with Comm 83.21.Wis.Adm.Code,petsotal information you provide ry <br /> C1 Check if Revision ma be used for seco s Priv Law,s15. 1)m) n D 3 <br /> I. Application Information-Please Print AB Information State Plan I.D. Number <br /> Property Owner's Name <br /> Parcel NutnbeT04�- d 4-G} <br /> an cltrr OI6` ?4J4 -e� ` (v10 <br /> Property Owner's Mailing Address <br /> /l <br /> / Property i l70 r e_4 (![-eL(/ !6 - SC:S dY T 39 N.R 17 E ) <br /> City.State Zip Code Phone Number Lot Numbe `,15 Block Number <br /> "vision Name 1 n CSM Number <br /> ma lr we jI)A/ SSS/9 j-p u I <br /> U. a of Building(check an that apply) <br /> ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village <br /> ❑Public/Commercial-Describe Use <br /> ti�1'ownship Lin cof'✓1 <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. 1 New 2 ❑ Replacement System 3 ❑ For County use <br /> Replacement of 6 [1 Addition to <br /> stem Tank Only 49— <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 rue) <br /> 44,E Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wedand <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 Raw(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 30� 43d- v3d . 7 9y 9 77, 41 <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 'f0 _ 7s0 <br /> Dosing Chamber �CQQ j-OQ <br /> Z4 1.41 7 <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 /> �l`FAaev r/s 2 ZS'$s' I 7 566- 44S-7 <br /> Plumber's Address(Street.City.State,Zip Code) i <br /> 2-77 &0 /4w 35 � <br /> VIIL County/Department Use Offly <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A nature(N turps) <br /> Surcharge Fee) �'q� <br /> ❑ Owner Given Initial Adverse ROD, W <br /> Determination v <br /> IX. Conditions of Approval/Reasons for Disapproval i <br /> �G <br /> �G9� y/Ut <br /> Attach complete plans(to the Comty only)for the system on paper net It"than 81/2 a 11 Inch"in size <br /> 90, <br /> SBD-6398 (R. 05101) <br />