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Safety and Buildings Division County Q <br /> 201 W. Washington Ave.,P.O.Box 7162 <br /> � Allaconsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce Sanitary Permit Number <br /> Sanitary Permit Application X578 3 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision ^n <br /> may be used for secondary purposes Privac Law,sl . I In State Plan I.D.Number W <br /> I. Application Information-Please Print All Information <br /> Parcel Number <br /> Property Owner's ame t <br /> Z, +N --t- C- �+6 .�5 Dao- 3a5-�3- <br /> Property Location <br /> Property Owner's Mailing Address `J <br /> �- 93 � Z W !d !6;S 6 T 7�N,RA� E <br /> City,State <br /> Zip Code Phone Number Lot Nu Block Number <br /> Subdivision Name CSM Number <br /> sy�o I 633-':27 o,4kl,+,Uo/s,40,^cs <br /> o n.J 2.Y c.t.J� <br /> H.Type of Building(check all that apply) ❑City <br /> V-1 or 2 Family Dwelling-Number of Bedrooms []Village <br /> ❑Public/Commercial-Describe Use J&ownship <br /> Nearest Road )J <br /> ❑State Owned �ylSrG� <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 g New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> For County use <br /> S stem Tank Only Exist'Existim System Date Issued <br /> B. ❑ Check.if Sanitary Permit Previously Issued <br /> Permit Number <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 KNon-Pressurized In-Ground 21❑ Mound <br /> 47❑ Sand Filter 50❑ Constructed Wetland <br /> 41❑ Holding Tank 48 El Single Pass 51❑Drip Line <br /> 22 13 Pressurized In-Ground � <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Arca Dispersal Area Soil Appiicadon Percolation Rate System Elevation Elevationde <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) <br /> 36o y� � y3 ,z . -7 9s,/ 97, E <br /> VI.Tank Info Capacity in Total Number. Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Facisung <br /> Tanks Tanks <br /> Septic or Holding Tank 5 b 7 <br /> Dosing Chamber 15'00 1 S`O d 7� <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Signamre MP/MPRS Number Business Phone Number <br /> Plumber's Name(Print) <br /> w 4d e, R, r, �d/ w C� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �e u siye-.J <br /> VIII. Coun /De artment Use Onlnature(N tamps) <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Ag g <br /> 4 Approved ❑ Disapproved Surcharge Fee) <br /> Ll owner Given Initial Adverse. e _1P <br /> Detertnina6o1 <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> AttarL complete Alam(W the County only)for the system on Paper not leas Wan 11/2 x 11 Inches is size <br /> SBD-6398 (R. 05/01) <br />