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Safety and Buildings Division County, <br /> 201 W. Washington Ave., P.O. Box 7162 to ir n <br /> df <br /> Nvisconsin Madison,WI 53707 -7162 Site Address <br /> Department of Commerce aD (} <br /> Sanitary Permit Application Sanitaryc/P/erD/m�it�2N7ur`/m�_b w <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ElCheckJ if Revision �� <br /> may be used for secondary purposes Privacy Law,sl,5-. (1)(m) <br /> I. Application Information-Please Print All Information �f-'��/ n,/j State Plan I.D.Number <br /> Property Owner's Name , Parcel Number <br /> y- Daa5-0a- C/ 0 0 <br /> Property Owner's Mai mg Address tj <br /> "`�� "��}�j 2 yPr�operty Location <br /> I1 a� / /J S&, 6/ goad 1 )431/aSS a T5�9N.R 15 <br /> City,State Zip Code <br /> PhonNumber Lot NmBlock Number <br /> Syg j Subdivision NamSM <br /> NumberS4.el ILo,klzr 3�o <br /> ACS Cart <br /> II.Type of Building(Check all that apply.) n ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms � [E,�lVillage <br /> p <br /> ❑ Public/Commercial-Describe Use tTownshi V <br /> ❑ State Owned Nearest Road Q <br /> III.Type of Permit: (Check only one box on line A. Numbering is for internal use.) (Complete line B,if applicable.) <br /> A. A New 3 13Replacement of 6 ElAddition to <br /> s[em 2❑Replacement System Tank Only Existing System For County use <br /> B. []Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of POWT System: (Check all that apply. Numbering is for internal use.) <br /> 44A Non-Pressurized In-Ground 21❑Mound 47❑ Sand Filter 50❑ Constructed Weiland <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 El 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/Sq.Ft.) (Min./Inch) Elevation <br /> 1/50 LoYS 6S,Y * 7 lel� 73, 0 �a• <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 /> ,CGO <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigns ,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) lumrr� i <br /> Core MP/MPRS Number Business Phone Number <br /> S Z) 7�5 �3aa-57o <br /> Plumber's Address(Su et,City,State,'Zip Code) <br /> VIII.County/Department Use Only <br /> Disapproved Date Issued ISsui Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial Adverse Sanitary Permit Fee(in l de Groundwater <br /> Determination Surcharge Fee) nQ, /0-IS-0 CJ` � ') <br /> IX.ISonditions of Approval/Reasons for Disapproval <br /> RECEIVE <br /> > > 2ooz <br /> Attach complete plans(to the County only)for the sys em on paper not less than 81/2 x it inches in size <br /> BURNEV OUNN <br /> zowNG <br /> SBD-6398 (R. 05/01) <br />