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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 tmr <br /> 14sconsin Madison,WI 53707-7162 Site 11Ad rens �p7 <br /> Department of Commerce C1q CC 1��, <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 Seco purposes Priv Laws 1 m ❑ Check if I.D.Num <br /> I. Application Information-Please Print All Information State Pian .D.Number <br /> a <br /> Property Owner's Name Parcel Number <br /> �v s Ono- y3D -Oa- /0-o <br /> Property Owner'sMailing Address Property Location <br /> 2.9460 &C- "- 'A .A:S T fq N.R <br /> City,State ` Zip Code Phone Number a Lot Number Block umber <br /> B.MNa UI W 1 � � 6�- 17-9 1 u diI.JfJtste v F l.e <br /> 11.Type of Budding(check all that apply) ❑city <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms Q ❑V <br /> fillage <br /> Public/Commercial-Describe Use � - rJn �p.�/ 71'0I Township <br /> ❑State Owned Nearest Road <br /> Ge <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 New 2 ❑ Replacement System 3 ❑ Replacementof 6 ❑ Addition to For County use <br /> S stem I I Tank Only Existing System <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 /> i <br /> 44Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ constructed Wetland <br /> 22 Pressurized Int-Ground 41❑ Holding Tank 48❑ Single Pass 51❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.D' 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 /> 30O q 432 -7 <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 /> New <br /> Tanks <br /> Septic or Holding Tank 0,60 ' N x <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibilitVinstallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) Plumber's Signature MP/MPRS Number Business Phone Number <br /> t-*WP 225$s' 1 715 sw 4S7 <br /> lumber's Address(Street,City.State,Zip Code) <br /> 2.7 7 (o 0 144 :315 Aam W1 , �4S 3 <br /> County/Department Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval 1 j <br /> n OCj 2. 4 2003 t' <br /> URNE- T COUNTY <br /> Attach complete plans(to the County only)for the syst less than 81/2 x Il inches in size <br /> SBD-6398 (R. 05101) <br />