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3. �, Safety and Buildings Division County <br /> jDe <br /> 201 W. Washington Ave.,P.O.Box 7162 r�Madison,WI 53707-7162 Sice Andrus <br /> !!S?fLmmerce L <br /> Sanitary Permit Application Sanitary Perm <br /> i �yef/7 T <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for sero ses Privac Law 15. 1 m ❑ Check if Revision <br /> I. Application Information-Please Print All Information <br /> State Plan I.D.Number <br /> Property Owner's Name <br /> (AtQJ1 &W Parcel Number \ <br /> 63a-53a$-Oq-4Z <br /> Property Owner's Mailing Address <br /> Property Loocation <br /> City,State W.477 Zip Code Phone Number k ` E ''4:S Z T N.R b E <br /> Lot Number Block Number <br /> 7/5) 6 - -3 y56 Subdivision Name CSM Number <br /> � 'S118y� <br /> IL Type of Building(check all that apply) <br /> N 1 or 2 FamilyDwell' '� (]city mg-Number of Bedrooms_ <br /> ❑Public/Commercial-Describe Use []Village <br /> ❑State Owned wownship <br /> III.Type of Permit: al <br /> only one box on line A (nttmbering scheme for internal use). Complete line Nearest Road B ,L�'! , / <br /> A. if applicable) <br /> 1 [I5 New 2 Replacenxm System 3 ❑ Replacement of 6 ❑ Addition toY <br /> For Count use <br /> S sum Tank Onl <br /> Exis' S sum <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(ntimbering scheme is for internal use) <br /> 44 V Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter <br /> 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass <br /> tn8 51❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersallTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application PP Percolation Rate System Elevation Final Grade <br /> �O Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 6�3 6�8 • 7 - 171 gg1 <br /> VI.Tank Info Capacity in Total Number Manufacturer <br /> Gallons Gallons of Tanks Prefab Site Steel Fiber Plastic <br /> New Exis6nQ Concrete Constructed Glass <br /> Tanks Tanks <br /> Septic or HoWirta Tank ,e _ / / <br /> Dosing Chunber Ak3rW6r;;Ce <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 <br /> MP/MPRS Number Business Phone Number <br /> � v ��s 2-2. S 711 46- q-1S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2.7 7 (o 0 gt X48 3 <br /> VIII. County/Department Use <br /> proved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued is Agent Signature(No S ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination �OD`" <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plana(to the County Dalt)tar the zystem on <br /> paper not less than 81/2 z 11 inches in size <br /> SBD-6398 (R. 05101) <br />