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lir/r N N 41/ <br /> Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 J' <br /> `iseonsin Madison,WI 53707-7162 Site Address <br /> De artment of Commerce Sanitary Pe tot Numberw <br /> Sanitary Permit Application zoZ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ElCheck f evi ton <br /> ma be used for secondary ses Privacy Law,s15. 1 m State Plan I.D.Number <br /> I. Application Information-Please Print All Information <br /> Parcel Num r <br /> Property Owner's Name S © / 551,2(1 O 1 e <br /> D <br /> (� /)1 e �' G Property Location /-�c- <br /> Property Owner's Mailing Address `�� I c� <br /> 3 S/!7 ,lUrn/ S4/c+ �/!4;S� T3/ N,R 7 <br /> City,State <br /> Zip Cade Phoma Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> e- s <br /> II.Type of Building(check all that apply) ❑City <br /> (11 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> �— na>vp Li .v c c� std <br /> ❑Public/Commercial-Describe Use Nearest Road <br /> ❑State Owned S/7J / <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B V applicable) <br /> A. 1 ❑ New 2,*Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> For County use <br /> Tank Onl Exis' System Date Issued <br /> S sttm permit Number <br /> B. L3Check if Sanitary Permit Previously Issued <br /> IV.Type of Permit: (Check all that al?piy)(numbering scheme is for internal use) 50 E3 Constructed Wetland <br /> 47❑ Sand Filter <br /> 44 ❑ Non-Pressurized In-Ground 24KMound <br /> 51❑Drip Line <br /> 41 ❑ Holding Tank 48❑ Single Pass <br /> 22 El Pressurized In-Ground41 <br /> 11 Other <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating <br /> V.Dis ersal/Treatment Area Information: Application Percolation Rate System Elevation Final Grade <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil App Elevation <br /> g Rate(Gals./Days/Sq.Ft.) (Min./Inch) <br /> Required Proposed <br /> 5003 Od 3© " <br /> / 15 <br /> Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> VI.Tank Info <br /> Gallons Gallons of Tanks Concrete Coacttucted Glass <br /> New Existing <br /> Tanks Talcs �L <br /> Septic or Eteldt WTmik-. 7J7 U /�— <br /> Dosing Chamber aD •� O J <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> MP/MPRS Number Business Phone Number <br /> Plumber's Name(Print) Plumber's Signature -:T yy`-7 _2 �6 <br /> Plumber's Address(Street,City.State,Zip Code) py <br /> �o je -.5—Z -.5 �.✓ %l F- —:5- <br /> yU 7�2 <br /> VIII. Count /De artment Use Onl <br /> Sanitary Permit Fee esGroundwater Date Issued Issuing A ent Signature( Ps. <br /> Approved El Disapproved Surcbarge Pee) <br /> ❑ Owner Given Initial Adverse j <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete pleas(to the 15=6only)for the system On PaPeT not less then 91/2 x Il tache in size <br /> SBD-6398 (R. 05/01) <br />