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Safe and Buildings Division County <br /> ,. <br /> 201 W. Washington Ave., P.O.Box 7162 <br /> sconsiln Madison,WI 53707-7162 Site Address <br /> Department of Commerce A-t6- <br /> Sanitary Permit Application Sanitary Pe quit Number # <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide `"3 7f8 <br /> may be used for sew ses Privac Law,s15. 1 m ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D.Numbe <br /> Property Owner's Name i- <br /> _7 Parcel Number C 3� <br /> 03 <br /> Property Owner's Mailing Address ap <br /> Property Lafs ` <br /> City,StateS FT-"7/) <br /> Zip Code Phone Number Lot Numberv� <br /> -71 5 Block Number <br /> -5-fc�v�k F��� s 5"41oa5' <br /> Subdivision Name CSM Number <br /> �/t� 0Z3£; <br /> II.Type of Building(check all that apply) <br /> ❑City <br /> 91 or 2 Family Dwelling-Number of Bedrooms <br /> []Village <br /> ❑Public/Commercial-Describe Use �-r <br /> El State Owned <br /> Nearest Road <br /> 1 !tel // <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. I,Q New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> Sy stem Tank Ord' <br /> ExistingS stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV-Try ie of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,gi Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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 reatment 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 /> 9o0 <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 Talcs <br /> epde r Holding Tank /DOU17'` & GD <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 S1 OUT MP/MPRS Number Business Phone Number <br /> ii/ `/ P7;1 `z ��SS''3 <br /> Pium is Address(Street,City,State,Zip ode) <br /> 7 / <br /> VIII. County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agen Signature( ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse ` Q� ����"l <br /> Determination (�/ / <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the Couaty only)for the system on paper not less than 87/3 x tl incha In size <br /> SBD-6398 (R. 05101) <br />