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-SV31 -V2� av <br /> Safety and Buildings Division County t <br /> 201 W. Washington Ave.,P.O. Box 7162 V�kCT� <br /> Iviscon sin Madison, WI 53707 -7162 Site Address (1 <br /> Department of Commerce ( IS � �� <br /> Sanitary Permit Number � <br /> Sanitary Permit Application 6 <br /> 1n accord with Comm 83.21,Wis.Adm. Code,personal information you provide ❑ Check if Revision ©3 u <br /> may be used for secondary purDoses Privacy Law, .04(l)(m) <br /> 1. Application Information-Please Print All Information l J3S State Plan I.D. Number 1 <br /> Property Owner's Name 'r( Parcel Number !�J <br /> lti�„v O32 -9D -®l- o <br /> Property Owner's Mailing Address Property Location <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> rSubdivis on Name CSM Number <br /> t.J 19rag ue, /J �f1r0 7 ur t <br /> H.Type of Building(check all that apply) ❑City <br /> I or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑ Public/Commercial-Describe Use RITownship 'S W f,55 <br /> ❑State 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 X New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank OnlyExistingSystem <br /> B. 11 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 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Welland <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.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) i Elevation <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 or Holding Tank <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature TP/MPRS Number Business Phone Number <br /> � cthRc�D ii✓S <br /> 2ZS$ S 1 7��- g66— 4157 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z7-7 &y fewy 35 IAosmx W( , X4893 <br /> VIII. Count /De artment Use Ofily <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing AgentAt— <br /> oved ❑ Disapproved Surcharg e) �y� <br /> ❑ Owner Given Initial Adverse �©(��� 6 <br /> Determination <br /> T.K. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x Il Inches in sae <br /> SBD-6398 (R. 05101) <br />