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Safety and Buildings Division County <br /> 201SW<< hington Ave., P.O.Box 7162 �GG/o/ <br /> `+ NiD�d'ison, WI 53707-7162 Site Address <br /> /�,onsin <br /> De artment of Commerce �7 7� <br /> Sanitary Permit Application Sa�taty Permit Number yJ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Chock if Revision <br /> tree be used for seco purposes PrivacyLaw,s15. 1 m <br /> Application Information—Please Print All Information State Plan I.D.Number <br /> Property Owner's Na Parcel Number <br /> r <br /> Property Owner's Mailing Address �I A� Property Lor�ca//Rion r <br /> ��5��` // . li.IYA%:S O TCity, State Zip Code Phone Number Loot NumberBlocSubdivision Name�✓l l��l , �59 -2FeIf /�, we� <br /> II.Type of Building(check all that apply) ❑City =� <br /> I or 2 Family Dwelling Number of Bedrooms ❑Village <br /> 0 Public/Commcroial-Describe Use JUTownship /U Q/U <br /> ❑ State Owned NeJLXst Road I A <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 /> A,=Ncw 2 ❑ Replacement Sysum� 3 ❑ Replacement of 6 ❑ Addition to Tank Only Existing System <br /> B. ❑ Chock 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) j <br /> 4-4 on-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wedan>d <br /> 22❑ Pressurized In-Ground 410 Holding Tank • 48❑ Single Pass 51 ❑Drip Line <br /> I <br /> 45 0 At-Grade 46 0 Aerobic Treatment Unit 49 0 RecUvuliting 30 0 Other <br /> V. Dis ersaU'I7reatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elcv160D Final Grade <br /> Required Proposed Rate(GalsJDays1Sq.FQ (Min.anch) Elevation <br /> 0�b 3 7S 3 77 AR, 9�'O" �6'� <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanta Concrete Constructed Glass <br /> Ncw P,;sting <br /> Tanks Tanks <br /> r Holding Tank <br /> Dosing Cumber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for lastallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbe' S' nature MP/1vIYRS Number Business Phone Number <br /> PI s Address treet,City,State,Zip ode) <br /> / Q k C3 <br /> VIII. County/Department Use Only - - <br /> Sanitary Permit Fee(includes Groundwater Date Lssucd. Lsnting at i ps) <br /> pprovcd ❑ Disapproved Surcharge Fe#❑ Owner Given Initial Adverse )6 2A 6 1 <br /> Determination <br /> U CU <br /> u <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> B RNETT COUNTY <br /> fefa-�-T ZONING�u�)i�E�, � )O--o�aJ-Q� <br /> i <br /> Attach complete plans(to the County only)for the system on paper not less than 8U2 x 11 inches 1n size <br /> SBD-6398 (R. 05101) <br />