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Safety and Buildings Division Co u ry e � <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> 7visconsin Madison,WI 53707 -7162 Site Address <br /> Department of Commerce 7 <br /> Sanitary Permit Number <br /> Sanitary Permit Application ❑ c��� <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,05.04(1)(m) <br /> I. Application Information-Please Print All Information Sate Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> Ozb 430Z 0 Ivo <br /> Prope Owner's Mailing Address Property Location <br /> Q G,��� k b;S T N,R 6 <br /> City,State O Zip Code Phone Number Lot Number <br /> 1 - S <br /> 54$3o (os� - 3 i 4 4 Subdivision Name CSM Number <br /> J�fFN�u y2 of 3 <br /> II.Type of Building(check all that apply) ' ❑City <br /> I or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑ Public/Commercial-Describe Use Township DRk/-�71/b <br /> ❑ State Owned Nearest Road <br /> C/R CLE; <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 ❑ New 2 Replacement System 3 ❑ Replacementof 6 ❑ Addition to <br /> S stem Tank Onl <br /> Existing S stem <br /> B. El Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44�Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50 El Constructed Wetland <br /> 22 Pressurized In-Ground <br /> 41 ❑ Holding Tank 48 El Single Pass 51❑Drip Line j <br /> ❑ <br /> 45❑ A[-Grade 46 C]Aerobic Treatment Unit 49[1 Recirculating 30❑Other <br /> i <br /> V.D' ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate I System Elevation i Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> i^J > O I / A{id cbugC <br /> qs4 - 9�*astic0 <br /> VI.Tank Info Capacity in Total Number Manufacmrer Prefab Site Steel Fiber <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /Q� 1 �DOL'7 MWE540 <br /> Dosing Clamber I <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> c4AIR-p /nlS 2 25$S 1 IS- g66- 4157 <br /> lumber's Address(Street,City,State,Zip Code) <br /> Z7-7 (o0 14w 35 <br /> I. Count /De artment Use 1 <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issu' g gent Sig ture(No Stamps) <br /> Approved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination U <br /> IX. Conditions of ApprovaUReasons for Disapproval <br /> SEP _ <br /> BURN S 202 ',,�f• <br /> Attach complete place+(to the County only)for the system ou paper not cess`-t Vry(� a /� , v <br /> G �a�vaaU. <br /> SBD-6398 (R. 05101) <br />