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Safety and bwldmgs DIVIg10n county f� <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> Sin Madison, WI 53707-7162 Site AdF7 tA.rn t7Y- <br /> . iseon dress <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 �D y n D <br /> rna be used for me ond as Privac Law, 15.04 IXm ❑ Check if Revision <br /> I. Application Information-Please Print All Information <br /> State Plan LD. Number <br /> Property Owner's Name ��0 95D <br /> Parcel Number —� <br /> .O n rs /moo ss 0 td, yds, al, r00 <br /> Property Owner's MaOiag Address <br /> Progeny location <br /> S3 IF0 Ca l?V /Q <br /> City,State ;Codc Pbone Number SN uESubdivi <br /> Sk/ 14:S 3 T N,R /S E <br /> Blcck Number <br /> ame CSM Numbr <br /> � •' l`f-= 3 lis- 866-5'9 S/ <br /> II.Type of Building(check all that apply) <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms ❑City <br /> Public/Commercial-Describe Use O.1:F.e e ❑village <br /> ❑State Owned UrOWnship �Ae-/e.s0 n <br /> Nearcs[Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete lin B if applic14H <br /> A. I ''l New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑Addition toy <br /> For Count use <br /> S stem Tanka <br /> Ord Existio S stem <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date luued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal Use) <br /> 44 0 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter <br /> 22❑ Pressurized In-Ground 41 ❑ HoldingTank 50❑ Cop Li Constructed Weiland <br /> 48❑ Single Past 51 C1 Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersal/Treatment Area Information: <br /> Design now(gpd) Dispersal Area Dispersal Area Soil Application <br /> Percolation RateRe9uired Proposed Rate(Gals./DayslSq.Fr.) (Min./Ircn) System Elevation Final Grade <br /> Elevation <br /> 7G• � /s� X00 . S _ 9/.s cr �7 <br /> VI.Tank Into Capacity N Total Number /7 / <br /> Manufacturer Prefab Site Seel Fiber <br /> Gallons Gallons of Tanks PI: .tic <br /> New Exiuing Concrete Constructed Glass <br /> Tads finks <br /> septk or Holding Tank 80Q <br /> Dosing Chamber 800 L .S/GA w' x <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) g MP/MPRS Number <br /> Plumber's Signature Business Phon:Number <br /> Plumber's Address(Sweet,Ciry,Stae,Zip Code) 7!-f S(� - 4/,5-7 <br /> 0(7760H. 3 s— Gt/edsren� r ✓1 s rjg93 <br /> •Count /De artment Uu Onl <br /> Approved ❑ Disapproved Sanitary Pettit Fee,--Groundwater Dare Issued [swing AS S' nature tar ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse dl <br /> Determination ff l/ O <br /> [X. Conditions of Approval/Reasons for Disapproval <br /> Attach complete ptanr(to the Couoty Doty)for the rystem on paper oq)err than al/g x 11 inch.in alae <br /> SBD-6398 (R. 05/01) <br />