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QMMIRu <br /> ildings Division Come, <br /> an he 201 W. Washington Aul P.O.Box 7162 Q <br /> `�Sconsin Madison,WI 53707-7162 Sim Address <br /> De artment Mill <br /> Sanitary Permit Application B[Nmry Permit Antrang, <br /> In accord with Comm 83.21,Wu.Adm.Code,penal Infnmution you provide ❑ Check if Revision /✓�85,.d�„� <br /> ma M used for sew s Pines Law,s15. 1 m <br /> I. Application Information--Pleam Print All Information Snle Pim LD.Number <br /> Prnperry Owner Name Pareei Number <br /> RL 5 �0 5 £ l Ll 0— 1 - 706 <br /> Property Ownal Model Adds[ <br /> (n1 Rr�l{ Property Cacauon <br /> Pho1.R <br /> Ciry.Bute 11,E �t `, Zip Code Phonc Number Lou Number Block Nrwber <br /> TP�3lUCJi W1 <br /> 9W3 C) ButivisonName CSM Number <br /> U.Type of Building('check all that apply) IJC' <br /> ($1or 2 FamBy Dwelling-Number of i edruoms <br /> UVil <br /> ❑Public/Commercial-Describe Use � <br /> ovenshi 1 <br /> Cl Sate Owned Nearer[Road <br /> D 10 <br /> IM Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B V applicable) <br /> A. i New Z 0 Rephcemenl System 3 Replacement of 6 0 Addition to Far County use <br /> S stem Tavk ON Existiv S ate. <br /> B. 0 Check if Sardnry Permit Previously Issued Fit mite Number Dam lamed <br /> f�xType of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> ""j �'Non-Pres trl lo-Ground 210 Mound 470 Sntl Filter 50 0 Committed Weard <br /> 22: Presmnred In-Oround 4111 Holding Tank 48 0 Sing].Pass 51 0 Dnp Line <br /> 45 0 At-Grade 4110 Aerobic Treatment Unit 49 0 Recircubill 30 0 Odor <br /> V.Dis ersaVfreatmenl Area Information: <br /> Design flow(gpd) ilpesal Arca Di,,.[Ara Soii Application Percoladnn Rate 5ysrcm Elcv on Final Grade <br /> ALO M Proposed Ram(Gals/Das/SFe) (Minllnch) LyMer 92,0Mullane. <br /> 00 � oo1jxv, er ✓VI.Tank Info pacity N Tout Number Montrea r Prefab Sim Sme Fiiallons Gallo. of Ta�u Coll Cmemcmd Ellma [ <br /> Term <br /> SWlieor Rotel.TaNr 1I �4�� <br /> Dosin[@amber <br /> VII.Responsibility Statement- 1,the residential assume responsibility for(vstallalian of she POWTS shown on the smal d pill.. <br /> PI .the - Name(Print) PI bcr's Sig MP/MIRS Number Hushsess Phorm Number <br /> e\ So n aa4e T(s- lea a-F6a- <br /> Plumber's Address IS City,Sure,Zip Cq <br /> �4soa e �. r wlS To <br /> . Count /De an Use Onl <br /> AMmred 0 Disapproved Seal Pero t Fee(includes Groundwater Parc Issued than on is.mre o mps) <br /> Surcharge Fee) <br /> Do <br /> , d p <br /> Gen Initial Advse <br /> D <br /> eto Giv <br /> n 4f 0 <br /> IX. Conditions of ApprovaVlte.o.far Disapproval <br /> Alma eomplae Form as the Courcy only)for the neem on pope not leu then avr.I I Inrbu to dee <br /> SBD-6398 (R. 05/01) <br />