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Safety and Buildings Division County <br /> ` 20l W. Washington Ave., P.O. Box 7162 <br /> Rcon in Madison, WI 53707 -7162 Site Address <br /> Department of Commerce �) <br /> Late- <br /> Department PerNon <br /> Sanitary Permit Application ,� a <br /> In accord with Comm 83.21,Wis. Adm. Code,personal information you provide ❑ Check if ma be used for second ses Privac Law,515.04(1 m) <br /> 1. Application Information-Please Print Ail Ltf ation Sam Plan Lr 9�t5 b/ 54�Property Owner's Name Parcel Numd0 <br /> r -L <br /> Property Owner's Mailing Address Property Location / <br /> Si 'R;S T N, I {7 E <br /> City,Stam Zip CodePhone Number Lot umber Block Number <br /> �� �` Su ivision Name CSM Number <br /> MPs , MN zIL, !Zusn. <br /> IT.Type of Building(check all that apply) ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑village <br /> ❑ Public/Commercial-Describe Use Township Alb <br /> ❑ Stam Owned Nearest Road <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> I�New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank Only <br /> ExistingSystem _ <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44�1 Non-Pressurized In-Ground 21❑ Mount 47 IJ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ElHolding Tank 48 ElSingle Pass 51 El 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 Rate System Elevation Final Grade <br /> Required Proposed Rate(Gds./Days/Sq.Ft.) (MmAnch) Elevation <br /> � 643 (04� 1 16 . o qg . o M141 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Sim Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 1000 14000 1 K•Q•W X <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's NamZelplll� Plumber's Signature MP/MPRS Number Business Phone Number <br /> z�SB s 1 IS7 <br /> ?lumber's Address(Street,City,Stam,Zip Cade) <br /> 2.7-Nov 14w4 35 -6B . -5440'13 <br /> VII . Cour/Deent Use 1Sanitary PermitFee(includes Groundwater Date Issued Issuing Signatur o Stamps) "Approvpproved Surcharge Fee) ��/� <br /> er Given Initial Adverse I ��l % /� �(.ination (V/ <br /> IX. Conditions of Approval/Reasons for Disapproval /"'C /2 _07 ,/ <br /> Attach complete plane(to the County only)for the syMem oo Pero Im Wan 81/2 x ll ruches io size <br /> SBD-6398 (R. 05/01) <br />