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Safety and Buildings Division County <br /> 1"INVisconsin 201 W. Washington Ave., P.O.Boz 7162 a � <br /> Madison, WI 53707-7162 Site Address <br /> Department of Commerce old NWy. 70 <br /> Sanitary Permit Application Sanitary Permit NUnk rr , <br /> In accord with Comm 83.21.Wis.Adm.Codetn ,personal information you provide �#f / 6, <br /> a be used for xco Ses Privac Law,s15. 1)(m ❑ Check if Revision <br /> I. Application Information-Please Print All Informadon <br /> State Plan I.D. Number <br /> Property Owner's Name O <br /> Parcel Number <br /> ClJri/ x/06 -Oa -�1�40 <br /> Property Owner's Mailing Address CSO <br /> Property Location <br /> City.State :S a T/� N �,R � <br /> L Zip Code Phone Number <br /> ? <br /> Lot Number Block Number <br /> 5$7/ A Subdivision Name SM Number <br /> 'U' � � spa <br /> II.Tyildi <br /> pe of Bung(check all that apply) <br /> 91 or 2 Family Dwelling-Number of Bedrooms_ 3 ❑City <br /> ❑Public/Commercial-Describe Use []village <br /> ❑State Owned Tawrohip �(� <br /> 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. <br /> 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Orl <br /> Ezis' S stem <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 /> 44XNon-Pressurized In-Ground 210 Mound <br /> 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single pass <br /> B 510Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatmeof Area Information: <br /> Design Flow(go) Dispersal Area Dispersal Area Soil A lication <br /> Required Percolation <br /> Inch Rate System Elevation Final Grade <br /> 9u Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) � � 7 Elevation <br /> ��o 6,� , � p <br /> VI.Tank in Capacityd $ / 70��� S <br /> in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Tanks Plastic <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> n r Holding Tank <br /> Dostag 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) Plu ber' Signature <br /> f MP/MPRS Number Business Phone Number <br /> Plumber's Address(Sweet,City,State,Z p Cade) <br /> C <br /> Count /De artment Use Only <br /> !Approved ❑ Disapproved Sanitary Ppppppmut Fee(includes Groundwater Date ued Issu' cot Si nice tamps) <br /> Surchare) , y�( � <br /> ❑ Owner Given Initial Adverse ��((JJ(��Y/) /ISJPP/v) <br /> Detertnimtion <br /> IAC. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 s 11 iaehea in size <br /> SBD-6398 (R. 05101) <br />