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Safety and Buildings Division County <br /> 1XV& 201 W. Washington Ave.,P.O. Box 7162sconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce .3o7iv <br /> Sanitary Pe mit Application Sanitary Permit Number <br /> In accord with Comm 83.21, is. dm.Code,personal information you provide ( /Sn 8 <br /> may be used for sec o ses Privac Law,s15.04(1 m) ❑ Check it evrsi <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> AJAM dC50Al03 — "51121 <br /> Property Owner's Mailing Address / Property Location /� <br /> l�f^ �14'" W lT'— 4:S I7 T I N, R S <br /> City,Sttasttee Zip Cade Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> H.Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedroom []Village <br /> ❑Public/Commercial-Describe Use -Ap W�SS <br /> ownshi <br /> ❑State Owned <br /> Nearest Road <br /> ' '7/l? SKHoSff.9W <br /> III. Type of Permit: (Check only one box n line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 ❑ New Replacement System I, 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> system Fed <br /> ExistingSystem <br /> B• ❑ Check if Sanitary Permit Previously Is Number Date Issued <br /> IV.Type of Permit: (Check all that app] g scheme is for internal use) <br /> 4�Non-Pressurized In-Ground 21❑ 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 30❑Other <br /> V.Dispersal/Treatment Area Information <br /> Design Flow(gpd) Dispersal Area D spersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required P posed Rate(Gals./Days/Sq.Ft.) (Min./inch) Elevation <br /> � 4_Z9 4_32 . 7 94 3 94, o <br /> VI. Tank Info Capacity in T w Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gai ons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank o Did ALO <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 /> c RDmd-s 2ZS8 s I 7,'S S66- 4is 7 <br /> Plumber's Address(Street,City,State,Zip Code). <br /> 2.7-7 to o }4w-f ' S , _�4$ 3 <br /> V I. Count /De artment Use CP61y <br /> Sanitary Permit Fee(includes Groundwater DatPTTry.,.0.02 <br /> Stamps) <br /> Approved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination (J(O <br /> IX. Conditions of Approval/Reasons for D pproval <br /> BURNTY <br /> ZONING <br /> Attach completelam(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 />