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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 <br /> NVIsconsin Madison,WI 53707-7162 Site Ad Less <br /> Department of Commerce 4 <br /> Sanitary Permit Application Sanitary Permit Number <br /> '/'3S 3 / 7 d9, <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(1m CX. <br /> I. Application Information-Please Print All Informati p Staft Plan I.D. <br /> S 9 Number 1 <br /> O '_ <br /> Property Owner's Name Parcel Number <br /> 01 63404 0240020 <br /> Property Owner's MailingAddress ��''rt��y Location <br /> 1st ►WI W. 6 !I:S f T N.R/7 <br /> City,State Zip Code Phone Number Lot Number Bltrck Number <br /> LS I 1� ) S,, 4S 1'��S4 Subdivision Name CSM Number <br /> S`('. PAUL/ M �j1 (y <br /> II.Type of Building(check all that apply) ❑City <br /> I or 2 Family Dwelling-Number of Bedrooms I W ❑vim <br /> ❑Public/Commercial-Describe Use ownship 14AIOUV <br /> ❑State Owned N Vt Road t�,/, <br /> 1F/U E 1lxiIv <br /> E - <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 r New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I I Tank Only Existing System <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 ❑ Non-Pressurized In-Grand 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41X Holding Tank 48❑Single Pass 51❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Disspemrs.11Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> �$R Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> I 9v <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete I Constructed Glass <br /> New I Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 0 <br /> 0 —+ 7-000 I W X <br /> Dosing Chamber I I + <br /> VII.Responsibility Statement- I,the tmdersiped,awe responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) Plumber's Signature MP/MPRS Number Business Phone Number <br /> D r/s - 7--Z-5$ <br /> tumbei s Address(Street.City.State.zip Code) <br /> 27 7 (o o 4 :% <br /> VIII. County/De artment Use Ofily <br /> Approved Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ignamre tamps) <br /> Surcharge Fee) <br /> C1 Owner Given Initial Adverse $- V � � b3 <br /> Determination <br /> IX.Conditions of Appr _ <br /> Code derlueck clesryn Floes Must remcw &6 hers w I50 6k/!Qn✓/D� (C"�� V <br /> AUY wc,4E4ser of WR5i6Wh7dd Fzo4w cud( &di0w26 W.54/A,4" A <br /> coa+0auktrnnl SFJInGTArJK�PJM/ eHhal6eR I(/Aa �Ef ro A)(J106 Fel- 7lrl6 lvtt/2C .l'>'bva10 SVSG' <br /> Attach complete plana(to the County only)for the system an paper not less than ala x 11 inches in she <br /> SBD-6398 (R. 05101) <br />