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Safety and Bmlaings UIVI810n county <br /> R 201 W. Washington Ave., P.O. Box 7162 �jprNe f <br /> rseonsin Madison. WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Pe rmn Number 47=5& <br /> Jam& <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide <br /> may be used for secondary s Privacy Law,s15. t)(m) ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> aca �f o3a -Sala-o1- �0� <br /> Property Owner's Mailing Address Property Location G6v �-r <br /> Z �w !f u:S /A TIL N.R�s <br /> City,State Zip Code hone Number Lot Number Block Number <br /> Subdivision Name CSM Numbe <br /> W,-lJ (�t ��z1:7l <br /> - Zl7� <br /> U.Type of Building(check all that apply) Ocity <br /> Gr I or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑Public/Cotnmercial-Describe Use Township 5(.",1�$ <br /> ❑State Owned <br /> Nearest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternaluse). Complete linee B B if if applicable) <br /> A. 17 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Ord Existin S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Da¢Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <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 Rate(Gals./Days/Sq.Ft.) (.Min./lnch) GI? qO 9 Elevation <br /> 1-10� C/is <br /> VI.Tank into Capacity in Total Number Manufacturer Prefab Site Si eel Fiber PI:.aie <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /Cob _ lode ( 5 i./�t j <br /> flasiny Chamber � <br /> VII. RespomiblBty Statement- 1,the undersigned, assume responsibility for installation of the POWTS shown on the attached PhLW. <br /> Plumber's Name(Print) Piu tier's Signature MP/MPRS Number Business Phon:Number <br /> 966- �/�7 <br /> Plumber's Address(Scree[,Ciry,Stam,Zip Cade) <br /> 07760 Nw we4el,, G./, 54g? <br /> VII . Count JDe a ment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing a Signamr ml ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> De[ermirution eJ C�+ <br /> IX. Conditions of Approval/Resuous for Disapproval <br /> Atuch complete plans(to the County only)for the system on Paper not less than 81/2 x l l inch;;to aim <br /> SBD-6398 (R. 05101) <br />