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Safety and Buildings Division Coun <br /> 201 W. Washington Ave., P.O. Box 7162 Gl �r1 <br /> isconsin Madison, WI 53707 -7162 Site Address C ' d _ <br /> Department of Commerce Sly WOQ�S <br /> Sanitary Permit Application Sardtary,Permit Number <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,s 041 in <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> 12& 94 / <br /> Property Owmr's N�` Parcel Number <br /> s f}n1 of oafl nJ Ohq- 3.3.-2 9- a z- <br /> Property Owrim's Mailing Address l t P^ro'ppeerty Lomdon <br /> oC 6 T/£ /l1C ,,y �%:5 T N. 6 <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> ,pp Subdivision Name CSM Number <br /> A o. cr,e J - menti <br /> II.Type of Building(check all that apply) �. ❑City <br /> �"2 Family Dwelling-Number of Bedrooms ❑village <br /> ❑Public/Commercial-Describe Use �— nship ,f�/iJ -G.✓o <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 applicable) <br /> A For County use <br /> 1 New 2 ❑ Replacement System 3 El Replacement of 6 C1 Addition m <br /> S stem Tank Ont <br /> Existing S stem <br /> B. El Check if Sanitary Permit Previously Issued <br /> Perini[Number Date Issued <br /> V.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 EJ Non-Pressurized In-Ground 21�p-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.Dis ersal/I'reatment Area Information: <br /> Design blow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> equired Proposed Ram(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 9�-VI3QokStatement- <br /> . Tank Infoity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> lons Gallons of Tanks Contrera Constructed Glass <br /> ExistingTanksSeptic or Holding -Dosing ChamberVII. Responst- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Nam / Plumber's Sigmw MP/MPRS Number Business Phone Number <br /> Aj <br /> 4 el <br /> Plumber's Address(Street,City,Stare,Z`p Code) <br /> 113cXs/ Y c„� <br /> VIII. Count /De artment Use Out — <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing elle gnatur Stamps) <br /> Approved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Initial Adverse 2 <br /> Determination J �!M <br /> IX. Conditions of ApprovaitReasom for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not Ina than 81/2 x 11 inches to size <br /> SBD-6398 (R. 05101) <br />