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Safety and Buildings Division Coumr <br /> 201 W. Washington Ave.P.O.Box 7162 bo tin <br /> SCOnsin Madison.WI 537M-7162 Six Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Permit Number Q <br /> In amid with Carom 83.21.Wis.Adm.Code.personal iofoamdon you provide ❑ Check if Revision 'TU� �3 <br /> maybe used far Lw,s15. lxu <br /> I. Application Information-Please Print AB Information � Stam Plan I.D.Number 20 9Xn <br /> C7zs <br /> Property Owm es Name _ Pascal Number <br /> C PA 4- Ar /y, r bb(P - .7 l -off baa <br /> Property Owner's Mania Address Property Location <br /> Sl9S b /' t-' A)6) M )it:S0� <br /> City.Sax tip Code phone Nmn6er I.a Number j� Block Number <br /> l06"1- <br /> S r /y/ Subdivision Name Q CSM Number <br /> /z- / -6k� n n dO <br /> H.'Type of Building(cbeelc all that apply) ❑Ci4 <br /> !R1 or 2 Family Dwelling-Number of Bedrooms ❑Vnbage <br /> ❑Public/Commercial-Describe Use ownsbi 4�_/l, s L 7-C- <br /> D state <br /> ❑Sax Owned <br /> Neatest Road <br /> Q � . <br /> �r r- <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete a if applicable) <br /> A. LJ4Nwr 2 ❑ Replacement System 3 ❑ Reptaament of 6❑ Addition to For Coumty use <br /> S stem Tank Only S <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Lund <br /> IV.Type of Permit (Cheek all that apply)(mmmbering scheme is for intetmd use) <br /> 4a ❑ Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Consuucled Wedad <br /> 22❑ Pressurized In-Ground 4j�klktkft Tuck 48❑Sink Pass 51❑Drip Unc <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 3o❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Ann Soil Application Percolation Rax System Elevation Final Grade <br /> Required Proposed Rae(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacouer Prefab site Steel Fiber plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Eaisk11 <br /> Taatt Taros <br /> septic or Holing Teak �� <br /> DosiM Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume ragms,b0ity for imtallatioun of the POWPS shown on the attached plains. <br /> Plumber's Name,(Prim) Phmnbe 's Sigature weber Bualuess Phone Number 91 <br /> Plumber's Address(Street.City.Sax.Zip ) <br /> liw it 06 g 5 <br /> VQI unt /De eat Use Only <br /> Approvedf!Di"Wroved Samrary Permit Fee(mehdes Gramdwater11 <br /> Dam issued lswirng Signm o Stamps) <br /> SurdurgeF �/ }��Owner G;van Initial Adverse �N 3011 /uV �Sxrmhutiun <br /> IX.Conditions of AppronUReasom for Disapproval <br /> Attach eenpere plans no rhe Cowryoatl)fr rhe wren ao paper oat less fist 11112 s 11 inches is she <br />