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Safety and Buildings Otvlsion county <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> `�ScO/1Sin Madison,WI 53707-7162 Site Address <br /> Department of Commerce Number. X� <br /> Sanitary Petmu Number C1 <br /> Sanitary Permit Application �7z257 XJ <br /> In accord with Comm 83.21.Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> M1111be uxd for eco xs Privac Law.515. 1 (m <br /> State Plan I.D.Number <br /> I. Application Information-please Print All Information00 <br /> Parcel Number <br /> Property Owner's Name <br /> Lk-FEK Z,,�,t&qs5nrr, SC�t2�/.� 03z-SZLe7— 02 5aO <br /> Property Owner's Mailing Address Property Location /�qRt O faT L,Z <br /> 1340 CD -a SE u nEu s-R"4 T V/ N.R 15-09.City.State Zip Code Phone Number Lot Number Black Number <br /> ,8RRCEL <br /> Subdivision Name CSM Numtx <br /> L.aK£ l)z 514?'71 Nd -7700 m * yl; U. Aa:S7 <br /> U.Type of Bullding(check all that apply) ocity — <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 2 Village — <br /> 0 Public/Commercial-Describe Use Township aS5 <br /> Nearest Road <br /> ❑State Owned <br /> III.Type of Permit: (Check only one box online A(numbering scheme for,internal use). Complete the B if applicabV) <br /> qB. <br /> For County use <br /> I New 2 0 Replacement System 3 0 Replacement of 6 0 Addition to <br /> system Tatlk Ont Existin S stem Date Issued <br /> ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Z Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wedand <br /> 3y-gO LFz r-00Holdi Tank 48 Single Pass 51 D Drip Line <br /> 22 El41 Pressurized In-Ground ng <br /> 45 11 At-Grade <br /> 46❑Aerobic Treatment Unit 49 D Recirculating 3o D Ocher <br /> V.Dispersal/Treatment Area Information: Final <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Race System Elevation Elevation <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber PV;tie <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or}IoWirKTata O - � <br /> Dosing Chamber ' <br /> VII. R ' it S i t- de ed, trine responsibi4ty for installation of the POWTS shown on the attached plans. <br /> s Sig e <br /> MP/MPKS Number Business Phon:Number <br /> rft)CAU <br /> 6228 COUNTY LINE ROD aa�879 <br /> PluUNEa�S C Zip <br /> gru ) <br /> vv�a �v f <br /> 71 R-A-15-7482 <br /> VUJ/Count /De artment Use Only tau s) <br /> Approved � Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuingo ignamre P <br /> Surcharge Fee) �� pep <br /> ❑ Owner Given Initial Adverse �U hu�'05 <br /> Determination <br /> IX. Conditions of ApprovaUReasons for Disapproval <br /> Attach complete plans(to the County only)No the system on PaPer not less than 81/2 s 11 inches in size <br /> SBD-6398 (R. 05/01) <br />