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Safety and Huudmgs utvision county <br /> ` 201 W. Washington Ave.,P.O. Box 7162 /6 %-1 /-fes e✓ <br /> seonsin Madison,WI 53707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Number <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> C1 Check if Revision <br /> may be used for seco2gM purposes Privacy Law,sIS. 1)(m <br /> I. Application Information-Please Print All Infonun* #�2State Plan I.D.Number <br /> % <br /> Property Owner's Name n Parcel Number / r 6A <br /> Property L7'Owwner's Mailing Address Property Location / / 00 <br /> 7 U tf u:S 6 T Q N.R E <br /> City,State Zip Code Phone Number Lot Nu ter Bleckber <br /> c ` <br /> S <br /> Subdivision Name CSM Numbe> �e.�J w� 5-` 87 3����ad 6A-K • A-W <br /> II.Type of Building(check all that apply) Dcity <br /> 6t 2 Family Dwelling-Number of Bedrooms (]Village _ <br /> ❑Public/Commercial-Describe Use ownship <br /> ❑State Owned Nearest Road /^1 <br /> F 1r <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal rue). Complete line B if applicable) �J <br /> A' 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Onl Existio S stem <br /> B. ❑ Check if Sanitary Permit Previously issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Y-Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Linc <br /> 45❑ At-Grade 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/Sq.Ft.) (Min.flneh) Elevation <br /> 3a �a 7 ys-d - 7 9 y t <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Si aic <br /> Gallons Gallons of Tanks Concrete Constructed <br /> New Existing <br /> Tr�anks Tanks <br /> Septic or -D �() D:-r / S �/ >Z— <br /> Dosing Chamber VV <br /> VII. Responsibility Statement- I,the undersigned,assume res risibility for installation of the POWTS shown on the attached plt.ns. <br /> Plumber's Name rint) Plumber's Sigmatur MP/MPRS Number Business Phone Number <br /> iJ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ®< 5—/ � s %/- <br /> to �- �.✓� L/8 <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin gent lure a ps) <br /> ❑ Owner Given[Initial Adverse Surcharge Fee) <br /> Determination <br /> IX. Conditions of ApprovaVReasons for Disapproval <br /> Attach complete plana(to the County only)for the system on paper not less than 81/2 t 11 Inches in Mist <br /> SBD-6398 (R. 05/01) <br />