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Safety and Buildings Division County <br /> Vsconsin 201 W. Washington Ave., P.O. Box 7162 <br /> Madison, WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Conon 83.21,Wis.Adm. Code,personal information you provide <br /> ma be used for second purposes PrivacyLaw,sIS. 1)(n,) ❑ Check if Revision <br /> L Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> )` BO ,I <br /> ropeny wner'sOOMailinig Address Property Location <br /> 1 <br /> D O GG( 2 4W S Tj:k N. R/4' E <br /> City,Sure Zip CodePhorc Number Lot Number Block Number <br /> Subdivision Name <br /> CSM Number <br /> 4 4/7 <br /> II Type of Building(check all that apply) Ociry <br /> I or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village <br /> ❑Public/Commercial-Describe Use ownship <br /> 13 State Owned Nearest Road <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 New 2 C1 Replacement System 3 C1Replacement of ti ❑ Addition[o For County use <br /> S stem Tank OnlyExistin S stem <br /> B ❑ Check if Sanitary Permit Previously Issued Permit Number Dare Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44Non-Pressurized In-Ground 210 Mound 47 11 Sand Filter 50 C] Constructed Wedand <br /> 22 Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑ Drip Line <br /> 45❑ At-Gado 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dispersal/Treatment Area Information: —1 <br /> Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Fual Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) �7 [ _ Elevation <br /> 1 -7 r `I 96- 97 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallows of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks TanksJ <br /> optic Holdint Tank ih- D <br /> tin amt !'7 <br /> _ZR <br /> VII. Responsibility Statement- 1,the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumper's Name(Print) Plum is ignature MP PRS Number Business Phone Number <br /> 17 <br /> 714- <br /> lumber' Address(5 et,City,State, Zip'Code) <br /> VIII. CountyIDe artment Use Only <br /> Approved ❑ Disapproved Samury Permit Fee(includes GrounsdwateF Ffz <br /> ing Signature Sumps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> I.A. Conditions of ApprovaUReaso u for Disapproval �• � n $Jb,)hrsxla I cbtlf <br /> Atuch complete plan,(to the County only)for the system on paper not less than 9I/1 s 11 inches in size <br /> SBD-6398 (R. 05/01) <br />