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Safety and Buildings Division county <br /> 201 W. Washington Ave., P.O. Box 7162 Qarn C7et <br /> risconsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce W.Y SChoamovev l�cP <br /> Sanitary Permit Application Sanitary Permit Number <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if RevisiA��I <br /> my be used for secondary us Privacy Law, 15. 1 (m <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> /0'a l PA".rig I (V A0— y3J 3 — 61`f/6 <br /> Property Owner's Mailing Address Property Location 6,DW't,(-0T <br /> Gi <br /> 'A 'A:S}3 T90 N.R/6 E <br /> City,Sate Zip Code Phone Number Lot Number' Black Number <br /> Subdivision Name CSM Numb: <br /> ff� �� vase nlN ss7�y �s� - 43�_ 0839 05M V 13 F SS <br /> II.Type of Building(check all that apply) ❑City <br /> f rl or 2 Family Dwelling-Number of Bedrooms 3 []Village _ <br /> ❑Public/Commercial-Describe Use ®Township Qrtk""' Q <br /> ❑Sate Owned Nearest Road <br /> 5. 1, onav<+ Roe <br /> III.Type of Permit: (Check only one box online A(numbering scheme for.internal stye). Complete line B if applicable) <br /> A. 1 ❑ New 2Replacement System 3 ❑ Replacement of 6 11Addition to For County use <br /> System I f I Tank Only Existing System.. <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> W.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 449 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 Linc <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersal/Treatment Area Information: <br /> Design Flow (gpd) Dispersal Arca Dispersal Area Soil Application Percolation Race System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/SgTt.) (Min./Inch) %3 Elevation <br /> iso '700 900 S- — -P. <br /> VI.Tank Info Capacity in Tom[ Number Manufacturer Prefab Site S'ecl Fiber PI; sic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plus. <br /> Business Phon:Number <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number <br /> /?tUc f/= ins / J�sasi 7/s-aro6-��s� <br /> Plumber's Address(Street,Ciry,Sure•Zip Code) <br /> 7 760 P;-y �Su/e6 rfr— .1 —<Z"873 <br /> I. Count /De artment Use Only <br /> Approved ❑ Disapproved <br /> Sanitary Permit Fee(includes Groundwater Dare Issued Issuing gent Signature(No Smi ps) <br /> Surcharge Fee) L n <br /> ❑ Owner Given Initial Adverse !1 -s�� G� <br /> Detersnlution <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete puns(to the County only)for the system on paper not less than 9112 s 11 inches to size <br /> SBD-6398 (R. 05/01) <br />