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2,2a 6l/ <br /> Safety and Buildings Division N County <br /> 201W. Washington Ave., P.O. Box 7162 <br /> Visconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce a � �' <br /> Sanitary Permit Applie MPUTEPjS S.'anitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide NEt� <br /> may be used for secondary purposes Private Law, 15. 1)m) ❑ Check if Revision /SQ - v <br /> I. Application Information-Please Print All Information Sate Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> �e Ol , Qloo OZ 300 <br /> Property Owner's Wailing Address Property Location <br /> i <br /> 277 G ti 'A:S i?e T #O N. R IT E ' <br /> City,Sate Zip Code Phone Number Lot rfnber Block Number <br /> Subdivision Name CSM Number - <br /> We fe l,.J • f�89 �7�) t�6-8�66' GEAR S!c A�nE <br /> 11.Type of Building(check all that apply) ❑City <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms z <br /> ❑Village <br /> 1 ❑Public/Commercial-Describe Use <br /> 11 State Owned Township q ��p IS <br /> Nearest Road <br /> ret S �9 <br /> III.Type of Permit: (Check only one box online A (numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 ❑ New 2 % Replacement System 3 ❑ Replacement of 6 11 Addition to For County use <br /> System Tank Only Existing System <br /> Permit Numberate DIssued <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> ! 44 V9 Non-Pressurized In-Ground 211) Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 3o❑Other <br /> V.Dis ersaVTreatment 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 ��rs <br /> 300 yz� y3z . -7 — 93o q63 <br /> vs.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 Ted; G X <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,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 /> zzS$S 1 715- S66- 4IS-7 <br /> lumber's Address(Street, City,Sate,Zip Code) <br /> Z7 7 !o o f4w 3,5 £8 , ]!;4$ 3 <br /> I. County/De artment Use Ofily <br /> pproved L1 Disapproved <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issu' Agent Signature(No Stamps) <br /> Fee) ���y�� w <br /> 11Owner Given Initial Adverse Surcharge Fe <br /> Determination <br /> IX. Conditions of Approval// easons for Disapproval / <br /> X�S6 s ,C'S AA, �11s�c7e�- <br /> i <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br />