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Safety and Buildings Uivnsion t.ounry <br /> ` <br /> 201 W. Washington Ave., P.O. Box 7162 Bu rn e f t <br /> rSconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce � 993 C4rgnbVerr Ln <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ,I ��C�� <br /> be used for second purposes Privacy Law 15.04 l)(m 11 Check if Revision L/. J <br /> I. Application Information-Please Print All Information Suit Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> Gar Vnrf2q,sse bad, 1761s, 6/300 <br /> Property Owner's Mailing Address Property Location <br /> 39/ State Rd 3s u u:S 3s T 4/ N.R 1(O41/_ <br /> City,State Zip Cade Phone Number Lot Number Bleck Number <br /> SubdivQision Name CSM NumN <br /> t�se:ed/e, W1 52/Od 0 7rS- %5-4497 1--71 <br /> II.Type or Building(check all that apply) ❑City <br /> Qr1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village _ <br /> ❑Public/Commercial-Describe Use ®'Township 5, i S.S <br /> ❑State Owned Nearest Road <br /> C`a1hbeve Ln <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 ❑ New 1 2�y Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Drily Existing System <br /> B- ❑ 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) <br /> 44p Non-Pressurized ln-Ground 21❑ Mound 47❑ Sand Filter 50❑ Comtmcmd 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. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Ram System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) e?S',-5- Elevation <br /> ql _o /43 (prig -7 — 919.01 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sicel Fiber Pi: aic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Foisting <br /> Tanks Tanks <br /> Septic or Holding Tank /p00 - /O 00 <br /> Dosing Cnamlxr 600 600 <br /> VII. Responsibility Statement- 1, the undersigned,assume responsibility for installation of the POWYS shown on the attached pl.ru. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Pbom:Number <br /> Plumber's Address(Street,City.State.Zip Code) <br /> 7760 3 s uyehjle.- w.L- syg93 <br /> . Count [Department Use Only <br /> Approved ❑ Disapproved Sanitary Peru',Fee(includes Groundwater Date Issuing A e gruture tar is) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse J-1 19/"Suc,ry 65 <br /> Determination 0 / <br /> IX. Conditions or ApprovalfReasons for Disapproval <br /> Attach complac plans(to the County only)for the system on paper not less than 91/2 x 11 inch"to sue <br /> SBD-6398 (R. 05/01) <br />