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Safety and Buildings Division County i <br /> I201 W. Washington Ave., P.O. Box 7162 f t <br /> fisconsin Madison, WI 53707 -7162 Site Address <br /> Department bf Commerce 70T 2 /612A <br /> JU <br /> Sanitary Permit Application Sanitary Permit Number <br /> ' /����� IC <br /> In accord with Comm 83.21,Wis. Adm. Code,personal information you provide <br /> may be used for second purposes Privacv Law 5.04(1)(m) ❑ Check if Revision `7 O <br /> I. Application Information-Please Print All Information State Plan t.D. N mber <br /> Property Owner's Name Parcel Number <br /> 100/N i 03 2 6_3 7 61 Soo <br /> Property Owner's Mailing Address O/ Property Location <br /> 4 e /�! IC.!%' 5" -R NES !4:S 2-7T L// N. R 6 Et+i.T <br /> City,State Zip Cade Phone Number Lot Number <br /> mber Block Number <br /> Subdivision Name CS%f Number <br /> 4 /ll SB60 07� /-3gY0 U. 3 26 <br /> U.Type of Building(check all that apply) ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms Z ❑Village <br /> ❑ Public/Commercial-Describe Use <br /> Township , <br /> ❑ State Owned Nearest Road <br /> 2MAj <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if a ppLicable) <br /> A. I New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition m For County use <br /> I <br /> System Tank Oniv Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number I Date I sued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal ase) <br /> 44 VNon-Pressurized In-Ground 21❑ Mound 47❑ Sand Filter 50❑ ConstructedWeiland j <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.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area i Soil Application Percolation Rate System El vation FL-.al Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min.ilnch) I Elevanon <br /> y32 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Si Sleet I Fiber t plastic <br /> Gallons . Gallons of Tanks Concrete Const cud Glass <br /> New Existing i i <br /> Tanks Tanks I 1 <br /> Septic or Holding Tank SQ _ 750 <br /> I <br /> Dosing Chamber �yt/t g ityrl <br /> V vii iii/ i <br /> 1 <br /> VII. Responsibility Statement- 1,the undersigned, assume responsibility for installation of the POWTS shown on the at ached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Numter <br /> �fFAtZ� xir/sHLVC4,tZ, ZzSS S I 7 5- S66- 4qS7 <br /> lumber's Address(Street,City,State,Zip Code) <br /> -27-7 (,o I4w <br /> I. CountyDepartment Use 1 <br /> proved ❑ Disapproved <br /> Sanitary Permit Fee(includes Groundwater 1 Date Issued­l Issuing Agcnt Signature No Stamps) <br /> W ^ <br /> Owner Given Initial Adverse Surcharge Fee) <br /> `'fith t,^✓kf/YIVI- OD <br /> Determination <br /> IX. Conditions of ApprovallReasons for Disapproval <br /> I <br /> I <br /> 1 <br /> I <br /> I <br /> Attach complete plans(to the County only)for the system on paper not less than SL:x I1 inches in size <br /> SBD-6398 (R. 05101) <br />