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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7082 <br /> W isconsin Madison'WI 53707-7082 Site Address <br /> Department of Commerce i'ALm LfME <br /> Sanitary Permit Application Sao` FfRi?"/��nb/er/yIn accord with Comm 8311,Wis.Adm.Code,personal information you provide "� / CCheckevision <br /> may he used for seconds purposes Privacy Law,s 15.04(I)(m) <br /> 1. Application Information-Please Print All Information State Plan I.D.Numb r j <br /> Pnq„m (4%,net's N//sure Parcel Number <br /> t6w l) p4wcc O2-`1-7035-0) 00 <br /> Property Owner's Mailing Address Property Location <br /> FO , Qeaf $78 t/, %:S 2 T 3 N R 14t1J <br /> City.State Zip Code Phone Number Lot Number Block Number <br /> f <br /> Subdivision CSM Number�utlSon GtJ� 55�v/!o 9i5-3�/- aSs b spa 4eS S t �ir-- <br /> 11.Type of Building(Check all that apply.) ❑City <br /> I-I or 2 Family Dwelling-Number of Bedrooms Villa❑ e <br /> ci Public/Commercial-Describe Use n g <br /> 0 State Owned ownshi <br /> st Road <br /> ALa-ea Lnnc, <br /> I1I.Type of Permit: (Check only one box on line A. Numbering is for internal use.) (Complete line B,if applicable.) <br /> A. 20 Replacement System 30 Replacement of 6p Addition to For County use <br /> stem Tank Only Existing System <br /> B. ❑Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of POWT System: (Ch k�all that apply. Numbering is for internal use.), <br /> 44�Non-Presstnized ln-Ground L 1 T 210 Mound 47 0 Sand Filter 500 Constructed Welland <br /> `C Pressurized In-Ground 410 1-folding Tank 48 0 Single Pass 51 0 Drip Line <br /> 11_-at-(aad, 46DAcrobic Treatment Unit 490 Recirculating 3000ther <br /> Dispersal/I reatment Area Information: <br /> Dcri,_n Flea (,>pd) Dispersal.Area Dispersal Area Soil Application Percolation Rate System Elevation Final( rad, <br /> Required Proposed Rotel GalsJDays/Sq.FLI (MinAnch) Flc'atum <br /> 66-3- -2 hlF't2.D �Sfo97.7� ' <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 crank. DOD <br /> Dosing Chamber <br /> VII.Responsibility Statement-L the undersigned,woune res sibility for ins!e f the POWTS shown on the attached plans. <br /> PI»mber'�T�tMlt �lC & .r.=:s+ .^Mp umber Business Phone Number <br /> �tYY11CCllii���v8 COUNTY L114E R �'� C52C;2 'r-7 S ' <br /> Plumber's Adth3 ,"t Z <br /> 715-635-7482 <br /> V111.County/Department Use Only <br /> 0 Disapproved Sanitary Permit (includes Groundwater Date ss Issu' ent i N O <br /> ved 0 Owner Given Initial Adverse Surcharge Fee �y <br /> Determination rV <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> V )) <br /> \torch complete Plant(to the County only)for the system on paper not less than a1/2 x I I inches in sire —�— • , - v / y <br /> .;RD-639R(R 05/01) <br />