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Safety and Buildings Division County <br /> Asconsin <br /> 201 W. Washington Ave., P.O.Box 7162 Madison,WI 53707 -7162 She Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide. ❑ Check if Revision 7$ <br /> ma / (�, v <br /> be used for secondary purposes Privacy Law,s15. 1 tn1 <br /> I. Application Information-Please Print All Information ffState Plan I.D.Number fit/ <br /> Property Owner's Name Parcel Number <br /> i// ev 61-3,7- F-730- O - Oo <br /> Property Owner's Mailing Address Property Location <br /> P. v. O .201 91 R:S�?7 T 91 N,R IT;K <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> � / ,f S 3d sir a y6 Subdivision Name CSM Number <br /> /.vrr- ihrleW¢ .eo � t <br /> D.Type of B 'ding(check all that apply) ^ ❑City <br /> V-1 or 2 Family Dwelling-Number of Bedrooms I I <br /> ❑Village <br /> ❑Public/Commercial-Describe Use ) Township .S 14/j f,f <br /> ❑State Owned Nearest Road <br /> La -r Or, <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for intemal use). Complete line B if applicable) <br /> `kTE] k <br /> 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition m For County use <br /> Tank Onl Exis' stemBif Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.�/Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> ad <br /> 44 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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.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.) (Min.Mch) Elevation <br /> Soo `f 129 175 &,. ya , 7 97 /00. v0 ' <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Crsa cvtfe <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> �Pllumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> iVCL��ee.c J. Qtnto Pas 760 86/ <br /> Plumber's Address(Street,City,State,Zip C//ode)We 't fe <br /> VIII Cotmt /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A Signature ps) <br /> Surcharge Fee) <br /> El Owner Given Initial Adverse. At /,� <br /> Determination yf (/ 092 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the"em on paper not len than 81/2 a Il Inches In size <br /> SBD-6398 (R. 05101) <br />