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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 Q oer <br /> ` l seonsin Madison, W I 53707 -7162 Site Address LaKe, <br /> a Ke Q(o t?-d. <br /> of Commerce t <br /> Sanitary Permit Application Sanitary Permit Number 0 60 9 L� <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide ❑ Check if Revision <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) <br /> I. Application Information-Please Print All Information J State Plan I.D. Number <br /> Property Owner's Name -�` Parcel Number <br /> 0 Cu}RK, 032, 2(9 os Sao A00/ <br /> Property Owner's Mailing Address Property Location 1 <br /> A <br /> 34 5-r- NEtti a:S T4� <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> 10 <br /> ��L i7L MAI <br /> � ' � S 9 0 607-nZsi- 1 K Subdivision Name CSM Number <br /> J� LJ-T 'i' <br /> H.Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms 4 []Village <br /> 8 <br /> ❑ Public/Cotmnercial-Describe Use ofownship (�✓� <br /> ❑State Owned Nearest Road J <br /> k 246 <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. For County use <br /> t�New 2 El Replacement System 3 ❑ Replacementof 6 ❑ Addition to <br /> System Tank Only Existing Sy stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> e of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> zliyp <br /> 44X Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Welland <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 Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 600 858 864 , 7 q3 4 9s 4 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic 1 <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank ;ZOO <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 SignatureMP/MPRS Number Business Phone Number <br /> *V� „�s zzs$51 7 ts- g66- 4s� <br /> lumber's Address(Street,City,State,Zip Code) <br /> 277 (oo f+w `3S UtEssrm -54147-3 <br /> V)II. County/Department Use Olbay <br /> Sanitary Permit Fee(includes Groundwater Date Issued IW <br /> t Signature(No Stamps) <br /> pproved ❑ Disapproved Surcharge Fee) ��--v Owner Given Initial Aderse am.W q-10-O�; <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plana(lo the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br />