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Safety and Buildings Dnvston county <br /> WX ,r 201 W. Washington Ave.,P.O. Box 7162 <br /> 1seonsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce 14. Bfts"w LK PA <br /> Sanitary Permit Application Sanitary/Permit Number 93 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ( �;L3 00L[ <br /> may be used for secondary purposes Privacy Law,s15. lxm ❑ Check if Revision <br /> I. Application Information-Please Print All Information L&—:If- �qcqq <br /> State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> C,"PA4ks f-LAIJAs.nl_: 501l 011 Z10-7- o boo <br /> Property Owner's Mailing Address Property Location yAcre5 L�{I f2- <br /> :Se 114 <br /> �1 0.tZor.-i3 SE u (lE u:S T58 N.R I'f1Jda <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Numbt <br /> %5P 00`wul` (i.� y -7 15-`f1b- 1 (o <br /> H.Type of Building(check all that apply) ❑Cin, _ <br /> 01 or 2 Family Dwelling-Number of Bedrooms_ ,j <br /> ❑Village <br /> ❑Public/Commercial-Describe Use [2Township 'D-e. J <br /> ❑State Owned Nearest Road <br /> &LbA5KF ,--D Lr4 <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 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Only Existing Sys <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 /> 44 0 Non-pressurized In•Grouod 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> EzFe,o&j <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/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Arca Dispersal Area Soil Application Percolation Rate System Elcvation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> So <br /> 1,43 W-b 17 /790r 17 4i•O 9519 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Swel Fiber PI:.;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Hwelietel <br /> eO 000 ,E X <br /> Desitin Chamber <br /> VII. Responsibility Statement- I,thelfundersigned,assume responsibility for installation of the POWTS shown on the attached phis. <br /> PwMN, p)& EXCAVA lurl SignaD#e MP/MaPsRS�Number <br /> Business Phon:Number <br /> Plumber"n <br /> t 1 t <br /> tv71r'VUV1Y r <br /> 71 <br /> I. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dare Issued Issuin Agent Signature(No Stan Ps) <br /> Surcharge Fee) <br /> Q Owner Given Initial Adverse a -0, <br /> Determination <br /> LX. Conditions of ApprovaVReasons for Disapproval <br /> JUL ? 3 � <br /> �i <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2!x 11 <br /> SBD-6398 (R. 05/01) Zorv/ U1V7Y <br />