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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7082 au,Nna't4' <br /> V. 4sconsin <br /> Madison,WI 53707—7082 Site Address <br /> Department of Commerce7002 <br /> Sanitary Permit Number <br /> Sanitary Permit Application 3 <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide Check if R vision <br /> may be used for secondary purposes Priva Law, 15.04 1 in O <br /> 1. application Information-Please Print All Information . State Plan LD.Number <br /> cok <br /> 10 <br /> Property Owner's Name Parcel Number <br /> A � pi'/—3103-OZ S00 <br /> Property Owner's Mail Address Property <br /> Property Location r20 Irl Z,p <br /> �JO $e/!01 T L9tct Y. Y.;S T N,R/ 6, <br /> City.State Zip•Code: Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> moAP./" tc�" Syd'O/ <br /> 11.Type Building(Check all that apply.) 0 City <br /> r�II or"_'Family Dwelling—Number of Bedrooms Z. C3� pVilinge <br /> D Public/Commercial—Describe Use Townshi sa <br /> State Owned Nearest Road <br /> E �.irwif LAr'E <br /> III.Type of Permit: (Check only one box on line A. Numbering is for internal use.) (Complete fine B,if applicable.) <br /> A. "New Replacement System 30 Replacement of 6p Addition to For County use <br /> S stem Tank OnlyExistina S stem <br /> B. D Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Tvpe of POWT System: (Check all that apply. Numbering is for internal use.). <br /> 44Non—Pressurized In-Ground 21 n Mound 47 0 Sand Filter 500 Constructed Wetland <br /> 22 D Pressurized In-Ground 410 Holding Tank 48 0 Single Pass 510 Drip Line <br /> 450 At-Grade 460 Aerobic Treatment Unit 490 Recirculating 3000ther <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.) (MmArich) Elevation <br /> 300 vJf �S e 7 Iliiv/ �i fsa/.0 fir 40 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Emsting <br /> Tanks Tanks <br /> Septic oa4lpldia8-Amk - <br /> D <br /> Dosing Chamber <br /> V11.Responsibilitv Statement-L t u rsigned, mine responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print L✓ Number Business Phone Number <br /> M&K SEPTI & ERi W1 54801 <br /> XC " <br /> ^115! bPK4NW- <br /> VIII. oun a t v <br /> Sanitary Permit Fee(inclu. u dw t// Date sued issuing nt Si o ps - <br /> roved 0 Owner Given Initial Adverse Surcharge Fee) - ��V `.j 13 <br /> Determination <br /> Conditions of ApprovaUReasons for Disapproval <br /> IJ-7 <br /> _1 NOIr fi `� <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 s 11hEafs%�ize <br /> E <br /> 2p NG COU <br /> SRn-639R (R. 05/01) <br />