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Safety and Buildings Division County <br /> All20 W. Washington Ave., P.O. Box 7162 Savri-e j`t <br /> 14sconsin <br /> Madison, W[ 53?07 -,7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number --- <br /> In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ��� O J D <br /> may be used for secondarypurposes Privacy Law,s15.04(U(m) <br /> 11 Check if Revision V <br /> I. Application Information-Please Print All Information State Plan LD. Number <br /> Property Owner's Name Parcel Number <br /> XM Y 613 fCN SOh �d'�' ff to(19 -0J /00 <br /> Property Owner's Mailing Address Property Location 6c)V'4__ LO-T3 <br /> 63301 <foa.✓!fv;0 1A 'A:S 6 T4i9N, RE <br /> City,State Zip Code Phone Number Lot Number Black Number <br /> Subdivision Name CSbt Number <br /> �oren f ray r ie M�✓ SS34(o V <br /> 11. Type of Building(check all that apply) [Icily <br /> X 1 or 2 Family Dwelling-Number of Bedrooms <br /> - ❑Village <br /> ❑ Public!Comtnercial-Describe Use <br /> Township Se )Y' <br /> ❑ State Owned Nearest Road <br /> y414Se. t Lk Tiov <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> PChe'�k <br /> w 2 ❑ Replazemeni System 3 ❑ Repiacement of 6 ❑ Addition to For County use <br /> Tank OnlyExistB. if Sanitary Permit Previously Issued Permit Number are Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal ruse) <br /> 44$yl Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑ Drip Line <br /> 45❑ At-G,-adz 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(Gals./Days/SgTt.) (Min./Inch) Elevation <br /> . 7 9/. 7 9e o <br /> VL 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 Tankz <br /> Septic or Holding Tank �4O - gaO y s.G,rY 41/ J/ <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 MP/MPRS Number Business Phone Number <br /> cillo vjw_s 566- ¢1S7 <br /> lumber's Address(Street,City,State, Zip Code) <br /> 27-7 &0 /4w 35 6B �4 $ 3 <br /> VIII. Count /De artment Use 1 <br /> Approved Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ge Signa o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse �J�n n f/� <br /> Determination oC�IJ oG71 <br /> IX. Conditions of Approval/Reasons for DisapprovalJUL 2004 <br /> J J� <br /> I it <br /> ,3 ( <br /> Attach complete plans(to the County only)for the system on paper not less than&V2 x 11 loches io s' <br /> TONING <br /> SBD-6398 (R. 05101) <br />