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wisconsin Madison, wI 53707 -7162 <br />I <br />Site Address <br />Department of Commerce <br />li <br />Sanitary Permit Application <br />SaniMq Permit Number <br />In accord with Comm 83.21, Wis. Adm. Code, personal information you provide <br />f' �( <br />T3 `f- D3 <br />ME'be used for ---0ndarY 22MSes Privacy Law, 315. 1)(m) <br />❑ Check if Revision <br />I. Application Information - Please Print All Information <br />State Plan I.D. Number <br />Property Owner's Name <br />Parcel Number <br />)0,4f 1- /9/ &/U <br />a�- 3/o8 -Olt +fee <br />Property Owner's Mailing Address <br />Jo0 <br />�} <br />31q.)-3 N�ISOYI ICGr/ ' <br />Property Location w� <br />5W lVF"A; <br />City, State Zip Code Phone Number <br />u S g T 39 N. R If1 E I <br />Lot Number <br />Block Number <br />1JAn bur' Gvr S �f830 S <br />Subdivision Nate C.SM Number <br />7/s-- 6�- 3184 <br />�,r0 �c�Es <br />U. Type of Building (check all that apply) <br />13 1 or 2 FamilyDwell' � <br />mg -Number of Bedrooms <br />city <br />❑V01 <br />❑ PubliclCommerc;al -Describe Use <br />❑Vl7lage <br />❑ State Owned <br />�Iownship /~?ksk <br />Near= Road <br />III. Type of Permit: (Check only one box on line A (numbering scheme for internal rise). <br />Complete line B if applicable) <br />A. For Cormty use <br />ti ❑Addition to <br />1 New 2 ❑Replacement System 3 ❑ Repiacemene7]Existing <br />stem Tank Onl S sum <br />B• ❑ Check if Sanitary Permit Previously Issued Permit Number <br />Date Issued <br />l V. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br />44 ® Non -Pressurized In -Ground 21❑ Mound 47 ❑ Sand Filter <br />50 ❑ Constructed Wetland <br />22 ❑ Pressurized In -Ground 41 ❑ Holding Tank 48 ❑ Single Pus <br />' <br />51 ❑ Drip Line l <br />45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating <br />30 ❑ Other <br />V. DispersaLlTreatment Area Information: <br />Design Flow (gpd) Dispersal Area D;spersal Arca Soil Applicatiea Percolation Rau System Elevation Final Grade <br />Required Proposed <br />Rate(Gais./Days/Sq.Ft.) (Min./lnch) u er /. 919 g` <br />3 oa,tip 'J 1, - Elevation � <br />`f 3� 600 -5, <br />/OWfr 9;• - 33. 9 7, <br />VI. Tank Info Capacity in TOW Number Manufacturer <br />Gallons Gallons of Tanks <br />Prefab Site Steel Fiber Plastic <br />i <br />New Esiui& <br />Concrete Constructed Glass <br />Turks Tanks <br />Septic or Holding Tank 7S-0 7So <br />1 <br />Dosing Chamber6-0 p Sr0 Q <br />VII. Responsibility Statement- I, the undersigned, assume r esponsibility for installation of the POWTS shown on the attached <br />Plumber's Name (Print) Plumber's Signature MP/MPRS Number <br />plans. <br />$usineu Phone Number <br />� �s $ s i <br />7 i 9(6- 44s7 <br />Plumber's Address (Street, City, State, Zip Code) <br />Z7-7 o 14w <br />1. Corm Department Use 01hly1 <br />pproved <br />❑ Disapproved <br />❑Owner Given Initial <br />Sanitary Permit Fee (includes Groundwater <br />Surcharge Fee),}} ate. <br />Date Issued <br />Issuing A t ignature o tamps) <br />j <br />Adverse <br />r � <br />Determination <br />f <br />IX. Condition <br />of Annroval/Reasonv fnr 11te-..,. <br />�......I <br />complete ptans (to the County only) for the syrtem oa paper not less than 81/2 x <br />SBD -6398 (R. 05/01) <br />�Li,L�'pG <br />