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Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 -� /s/L) e <br /> Visconsin Madison, WI 53707 -7162 Si ___ <br /> te Address <br /> Department of Commerce _— Qqng <br /> Sanitary Permit Application Salutary Permit Number t\ <br /> In accord with Comm 83.21,Wis. Adm. Code,personal information you provide 17J Check if Revision �� 3107 �1 <br /> may be used for second purposes PrivacyLaw, &15.04 1 m __ <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> 1,3,? .35So ---- <br /> Property Owner's Name Parcel Number <br /> 4 <br /> ke L-e-c- 33 03 Svo <br /> Property Owner's Mailing Addre Property Location P <br /> / 7 .S'[J 'R5`0-A:S3 T3 N,R <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> r <br /> H./Type of Building(check all that apply) ❑City <br /> ❑-f 1 or 2 Family Dwelling-Number of Bedrooms __ ❑Village__ <br /> 42ublic/Commercial-Describe Use_ p —_-- ownship /}/6 eii✓0"' --- -_ <br /> ❑State Owned Nearest Road <br /> „C <br /> III. Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if plicable) <br /> A For County use <br /> 1 ew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to S stem Tank On[ Existin S stem __ ___ _ <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Datc Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 21❑ Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 W­Ilolding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatment Area Information: _ _ -------� <br /> Design Flow(gpd) Dispersal Area Dispersai Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> Ncw Existing <br /> Tanks Tanks <br /> 3eptie-a,Holding Tank �Dd - pL` O o u /�”(nJ <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 Signsa MP/MFRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> f <br /> nConditions <br /> ment Use Cal _.— <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issmng n[SignaNre(No Stamps) <br /> pproved Surcharge Fee) <br /> ner Given Initial Adverse 2 ��i <br /> ination 3l <br /> provaUReasons for Disapproval <br /> Attach complete plans(b the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 05101) <br />