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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 a/'nJ <br /> Visconsin Madison,WI 53707-7162 Sire Address <br /> Department of Commerce Sanitary Permit Number <br /> Sanitary Permit Application ���a� <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide C1 Check if Revision <br /> may be used for secondary purposes Privacy Law,s15. 1)(M) State Plan I.D.Nymbe <br /> I. Application m <br /> Inforation-Please Print AB Information <br /> Parcel Number <br /> Property Owner's Name <br /> o A-) � /0r AIL—f— ��P � C66- q10 - l- 00 <br /> Property Owner's Mailing Address / Property Location <br /> ) 55--7 O e�/ t ' 'A 4;5 T SVG N,R T E <br /> City,State Zip Code Phone Number Lot Number e <br /> Swbdwiflian Nare CSM Number <br /> von; e-(I �✓`� sy6 35= 5-77 V 8' 9 <br /> .Type of Building(check all that apply) ❑City <br /> or 2 Family Dwelling-Number of Bedrooms ❑village <br /> ❑Public/Commercial-Describe Use "�— ownshiP S G- <br /> ❑State Owned Nearest Road <br /> Gp <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 New 2 Replacerrent System 3 ❑ Replacetnent of 6 11 Addition to <br /> S stem Tank Onl Exis' sum <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Petmit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 21)3'Mound 47❑ Sand Filter 5o❑ Constructed Welland <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.Dis ersal/Treatment 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 /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Concrete ConstruSite d Steel Giber Plastic <br /> Gallons Gallons of Tanks <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Dosing Chamber Sav SCY) <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility[or installation of the POWTS shown on the attached plans. <br /> Plumber's Name( t) Plumber's Signature MP/MPRS Number Business Phone Number <br /> -7a <br /> Plumber's <br /> S�,C <br /> Plumber'��s5/Address(Street,City,State,Zip Code) (/may <br /> VIII. Cotm /De artment Use Only <br /> Sanitary Pernut a(includes Groundwater ate Is ued Is su' A nt Si S ps) <br /> Approved <br /> El Surcharge Fee <br /> ❑ Owner Given initial Adverse a5ar Q <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system oo PaPer not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />