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z, <br /> Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> Msconsin Madison,WI 53707-7162 Site Add ss / 2 <br /> Department of Commerce 635 <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision 4a3/) "o <br /> may be used for secondary purposes Privacy Law, 1 m <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name - Parcel Number <br /> -Sw lj0p.)Srp'O" 0/19--3326-6?-Dot) <br /> Property Owner's Mailing Address <br /> Al- roperty Location / <br /> S Df*J A 14 S 266 N,R ` <br /> City,State Zip Code Phone Number Lot Number , L <br /> I <br /> MP �L / a / �S�1 0 /_t�7 „Wtr2-2718 Subdivision Name CSM Number <br /> II.Type of/Build ng(check all that apply) 6 (Q L L / !Q ❑City <br /> I or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> /❑ Public/Commercial-Describe Use <br /> owttship <br /> ❑State Owned Nearest Road <br /> M1QrWAJ a. <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line if applicable) <br /> A. 1 ❑ New I 2X Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> system Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> I <br /> IV.Type of Permit: (Check all that ap ply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 21 ound 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 Informs on: <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 /> 0 — 100. -�?4 /fl2. 24 <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 2a 34v4ij <br /> Dosing Chamber Via OO <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plaits. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> c el �r/s z2SS s l 715- $66- 4157 <br /> lumber's Address(Street,City,State,Zip Code) <br /> 27 7 (,o o /4w-f 6B , _�4as3 <br /> I. County/Department Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Is . Agent Sig cure(No Stamps) <br /> Surcharge Fee) (� i <br /> ❑ Owner Given Initial Adverse � a Sbz 00I I'� <br /> Determination <br /> ���ffff'"���f <br /> IX. Conditions of A proval <br /> API 15 2003 <br /> BURNh I I V t a l g the County may)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05/01) ZONING <br />