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Safety and Buildings utvaton county <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> `�sconsln Madison, WI 53707-7162 Site Address <br /> Department of Commerce 511#1 <br /> Sanitary Permit Application Sanitary Pettit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ' I <br /> ❑ Check if Revision <br /> my be used for secondary Virposes Pr vacy Law, 5. 1xm <br /> I. Application Information-Please Print All Information /? Sate Plan I.D. Number <br /> (, t <br /> Property Owner's Namc Parcel Number <br /> Torw'j > 1 012 1/2m 6 006 <br /> PropertyOwner's Mailing <br /> rr)Address <br /> / Property Location <br /> ZOtyW C� !f 14;S -b it} N,R/45 <br /> City,Sate Zip Cote Phone Number Lot Number Blcck:lumber <br /> l Subdivision Name CSM Numbe <br /> ibuf W 5-1Ld90 zSq - 3M'F 60vtt.� -j <br /> Type of DuElding(check all that apply) ❑City <br /> �77 <br /> 1X1 or 2 Family Dwelling-Number of Bedrooms G— <br /> ❑Village <br /> ❑Public/Commercial-Describe Use 9—Township <br /> ❑Sate Owned Nearest Road / <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B if applicablu) <br /> A' I ❑ New 2 V Replacement System 3 ❑ Replacement or 6 ❑ Addition to For County use <br /> a <br /> S stem Tank Ordy Existizig System <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Dame Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ( Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Construcrcd Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Gr-adc 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 Ram(Ga1sJDaysISq.Ft.) (.Nin.flnch) Elevation <br /> _77A' yam/ 113z 7 - <br /> VI.Tank Info Capacity in Toa[ Number Manufacturer Prefab Site Seel Fiber Ph sic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Esining <br /> Tank Tanks <br /> Septic or Hoidmt Tank A..,t1 00 t it t - I <br /> Dosing Chamber Ol/(l (JC/(J �J`-✓\/ <br /> VII. Responsibility Statement- I,the undersigned,assume retpoaibility for Installation of the POWTS shows on the attached pL.w. <br /> x <br /> is Name(Print) Plu is Signature MPIMPRS Number Business Pbon:Number <br /> 7 <br /> r's Address(Street,Ciry,State,Zip Code) <br /> 27T w <br /> Count /De art ent Use Only <br /> P Approved ❑ DisapprovedSanitary Permit Fee(includes Groundwater Date Issued Issuing a ignature(N n ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse ° <br /> Determination 10- 07- OS 65 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plana bo the C000ty only)for the system on paper net has then 31/2 a 11 inches in size <br /> SBD-6398 (R. 05/01) <br />