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uaca in on Ave.. vu� <br /> 201 W.wash;ngtoa Ave.,P.O.Boz 7VD <br /> onsin Madison,W1 53707-7162 Sim Address <br /> ent of Commerce <br /> Sanitary Permit Number (�Q <br /> Sanitary Permit Application ,/I 2 r� <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision *3`LC)3 2/ <br /> may be used for sworsdary.purpows Privacy Law, <br /> dcation Information-Please Print All Information Sate Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> (3 t- eIn Snow c{ 036` 4N44 - 0).300 <br /> Property Owner's Address Property Location <br /> ,- 7961 6o, Rel. Fl� SW u /"IA;S Ah T 40 N.R /7 <br /> City.Sate Zip Code Phone Number Lot Number Block Number <br /> I <br /> U/,(1h S�Yr S-461413 <br /> 7/S' gbh— 7ys-J Subdivision Name CSM Number <br /> U.Type of Building(check all that apply) �l ❑City <br /> i�.l or 2 Family Dwelling-Number of Bedrooms T ❑VillaBe <br /> ❑Public/Commercial-Describe Use Township un 16ki i <br /> ❑Sate Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal rue). Complete line B if applicable) <br /> A. 1 (j New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> stem Tank Only Existing S stem <br /> B. C3Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> i <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal rue) <br /> 44 6 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland i <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❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Sod Application Percolation Rate System Elevation Fina)Grade <br /> / /} Required,1 Proposed Rate(Gab./Days/SgXt.) (Min./Inch) idle er 9S•I Elevation 97. <br /> 606 <br /> 0 �4`VO ��OQ • lower- <br /> VI. <br /> owerVI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber I Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing i <br /> Talcs Tanks ; <br /> Septic or Holding Tank 1�so - 1 ,5 k 4 w <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,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 /> oAaev ,/✓s ZzS$ < 1 15- 566- 41s- <br /> lumber's Address(Street,City.Sate,Zip Code) <br /> 27-7 (o o f+W �JgB , <br /> VJ <br /> I. County/Department Use t"M <br /> A roved ❑ Dista roved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ignamr Stamps) <br /> Surcharge Fee) 7� ! <br /> ❑ Owner Given Initial Adverse ZD, W &*03 <br /> Determination <br /> as <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> ° <br /> e <br /> Attach mospiete plans(to the County only)for the system m paper not less than 91/2 x it Inches in size <br /> 20N�ry6 Uyin <br /> SBD-6398 (R. 05/01) ,✓ <br />