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Safety and Buildings Division County p <br /> 201 W.Washington Ave.,P.O. Box 7162 Bar n +C/ <br /> consin Madison,WI 53707 -7162 Site Address <br /> Department of Commerce Sanitary Permit Number <br /> Sanitary Permit Application SS �3 <br /> In accord will,Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> may he used for second u ses Privac Law s15.04(1 (m) State Plan I.D. Number <br /> I. Application Information-Please Print All Information . <br /> Parcel Number <br /> Property Owner's Name Uig y)3(�• d d�Oq <br /> Dwane J-dihn5ayl Property Location Gov)-,(,•07 I � <br /> Property Owner's Mailing Address /• C1 <br /> J 7�S'O !�i/l /QA "'k S4:S 3(a T N,R l4 <br /> Zip Code Phone Number Lot Number Block Number <br /> City,State .3 <br /> Subdivision Name CSM Number <br /> Speon2✓ 1N j' Sqv 7/o3��f�1 S3N7 v, t P OL03 <br /> II,Type of Building(check all that apply) 7 ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑ Public/Commercial-Describe Use <br /> ®'Township <br /> Nearer[Road <br /> ❑State Owned <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> For County use <br /> A' 1 ❑ New 2 X Replacement System 3 11Replacement of 6 ❑ Addition to <br /> S stem Tank Onl Exist in S stem <br /> B. [I Check if Sanitary Permit Previously Issued Permit Number Date issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) 50❑ Constructed Wetland <br /> 44Y IVon-Pressurized In-Ground 21 El Mound <br /> 47❑ Sand Filter <br /> 22❑ Pressurized In-Ground <br /> 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating <br /> 30❑Other <br /> V.Dis ersal/Treatment Area Information: Percolation Rate System Elevation Final Grade <br /> Design flow(gpd) Dispersal Area Dispersal Area Soil Application Elevation <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) <br /> 360 4/,w? 4 3d, 7 <br /> Capacity in Total Number t Manufacturer Prefab Site Steel Fiber Plastic <br /> VI.Tank Info P ty Concrete Constructed Glass <br /> Gallons Gallons of Tanks <br /> New Existing <br /> Tanks Tanks .1 X <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> ion of the POWTS shown on attached <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for instPlumber's Name(Print) allatthBuslim s Phone Number <br /> Plumber's Signature MP/MPRS Number _ J <br /> ,� . L / �n iy � I �IS- <br /> lumber s Address(Street,City,Stare,Zip Code) <br /> 27 7 &o 14w �S EB �48 3 <br /> VIII. Count /De artment Use Ofil Date Issued Issuing A t gnature(N mps) <br /> anitary Permit Fee(includes Groundwater <br /> Approved El Disapproved Surcharge Fee) <br /> El Owner Given S <br /> Initial Adverse <br /> Determination <br /> IX. Conditions of ApprovaUReasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less then gl/2 x Il Inches in size <br /> SBD-6398 (R. 05/01) <br />