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Safety and Buildings Division County <br /> Ksconsin <br /> 201 W. Washington Ave.,P.O. Box 7162 �f`Madison, WI 53707 -7162 Site Address <br /> De artment of Commerce ��, <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide (, <br /> may be used for secondary purposes Privacy Law s15. 1 m) ❑ Check if Revision " <br /> I. Application Information-Please Print Ail Information Sate Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> `^hlv 03a-533a-03- aGD <br /> Property Owner's Mailing Address Property Location <br /> ''A 4;S 32 T (N,R 16 E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> Ct� N 1157_JAq_0 <br /> II.Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms Z ❑Village <br /> ❑ Public/Commercial-Describe Use <br /> [Township <br /> ❑State Owned Nearest Road <br /> eD ,F <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A' 1 9 New 2 11 Replacement System 3 C3Replacement of 6 ❑ Addition to For County use <br /> System I Tank Only Exis' S stem <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 W Non-Pressurized In-Ground 2111 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./Inch) Elevation <br /> 1506 yZ� x'32 - 7 I!/ V/ <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 <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 Signature MP/MPRS Number Business Phone Number <br /> ook?p /,✓s z2S$SI 115- 9(6- 4157 <br /> Number's Address(Street,City,State,Zip Code) <br /> 277 (a 0 144 315 _�4as3 <br /> VIVI. County/De artment Use Ofily <br /> Approved ❑ Disapproved Surcharge a FPermit Fee(includes Groundwater Date ssued Iss Agent Signa re(No Stamps) <br /> ❑ Owner Given Initial Adverse ) A D-0 <br /> c ��JJ <br /> Determination l <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> J <br /> Oct � 2� <br /> F� <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> G �Y <br /> SBD-6398 (R. 05101) <br />