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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 �� <br /> Vvisconsin Madison,WI 53707 -7162 Site Address <br /> De artment of Commerce aloy� <br /> Sanitary Permit Number /[I�93 y1 <br /> Sanitary Permit Application J 7 <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, 1 m <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> t <br /> Property Owner's Name Parcel Number <br /> ozy- 310 - c5� - 3o0 <br /> Property Owner's Mailing Address Property Location <br /> 5,7e / NWL4 -7 ] 54V% S4:S �i T �1 N,R1�{ <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> �RN�3v2�� rnJt . Sy83o w - <br /> 11.Type of Building(check all that apply) ❑City <br /> X1 or 2 Family Dwelling-Number of Bedrooms eY. ❑Village <br /> ❑Public/Commercial-Describe Use Wownship Ru 5rL <br /> ❑State Owned 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 For County use <br /> 1 C1 New 2�Replacentent System 3 El Replacement of 6 11 Addition to <br /> S sum \\ Tank Onl Exist' S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Ion-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wedand <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 ersal/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.) (Min./Inch) Elevation <br /> 300 921 7 ��-�" �y <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Concrete ConStte tmcted Steel Fiber Plastic <br /> Gallons Gallons of Tanks <br /> ass <br /> New P.mung �L7��2 (OA-�IZL-TE <br /> Tanks Tanks <br /> Septic or Holding Tank ?S - 7 5tJ We)D y7^� <br /> Dosing 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) Plumbe ' ture MP/MPRS Number Business Phone Number <br /> r)DNA�7 t=• �2r7rf�T- % -��� az���o ?�5-- z�-3so9 <br /> Plumber's AddresiDetennination,State,Zip Code) <br /> VIII. Count /DUse OnlSanitary Perini a(includes Groundwater Date Issues Issuing Agent Signstu (N <br /> roved ved Surciven Initial Adverse <br /> 1X.Conditions of Approval/Reasons for Disapproval <br /> DECEIVED <br /> Attach comPI plans(to the County only)for the system on paper not less then 81/2 x 11 loeh ie e <br /> SBD-6398 (R. 05/01) 13UR I . COUNTY <br /> ZONING <br />