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Safety and Buildings Division County <br /> m 201 W. Washington Ave.,P.O.Boz 7162 8u rn t*- <br /> ` <br /> con <br /> C,/1 Madison,WI 53707-7162 Sim Address <br /> VV Ls7 •a�� i <br /> De artment of Commerce bion <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision �� <br /> may be used for secondary purposes Privacy Law,s 5. t m <br /> I. Application Information-Please Print All Information Shue Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> G I kes{e c k; J oia wo/ 0/100 <br /> Property Owner's Mailing Address Property Location <br /> 69 y,Ao T w u 5E u;S 7 T 4,e N,R 47 w. <br /> City,Sum tip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> T/n/ Park _Z[. (00477 log- Sia-dy47 Le-I � <br /> I allb <br /> D.Type of Building(check all that apply) QCity <br /> 111 or 2 Family Dwelling-Number of Bedroom 0vtlage <br /> 0 Public/Commercial-Describe Use ATowmhi Ja(AC-S. <br /> 0 Stam Owned Nearest Road Se,ben Rd. <br /> III.Type of Permit: (Check only one box on Hue A(numbering scheme for internal rise). Complete line B if applicable) <br /> A. 1 0 New 2 0 Replacement System 3 0 Replacement of6 � Additlon m For County use <br /> System Tank Only Eais' S stem <br /> B. 0 Check if Sanitary Permit Previously Issued Perrot Number Dam Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 X Non-Pressurized In-Ground 210 Mound 47 0 Sand Filter 50 0 Constructed Wetland <br /> 22 0 Pressurized In-Ground 41 0 Holding Tank 48 0 Single Pass 510 Drip Line <br /> 45 0 At-Grade 46 C Aerobic Treatment Unit 49 0 Recirculating 30 0 Other <br /> V. Die ersal/Treatmenl Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Sod Application Percolation Ram System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./ineh) Elevation <br /> 300 4/.9 4Y 3d — . 7 9G• d /oO. o <br /> VI.Tank Info Capacity in Tont Number Manufacmmr Prefab Sim Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank *ptp 8G� take w <br /> Dosing Clamber <br /> VII, Responsibility Statement- 1,the Imden ped,amume respomhbday for Installation of the POW7'S shown on the attached place. <br /> Plumber's Name(Prim) Plumber's Signamm MP/MPRS Number Business Phone Number <br /> 2258 S I S- 566- 4157 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 277 (oo /4w 155 Ueagm , -54S,73 <br /> V . Count /Department Use <br /> Approved 0 Disapproved Sanitary Permit Fee(includes Groundwater Dam Issued lans;r Zia Sumps) <br /> Surcharge Fee) <br /> 0 Owner tion Initial Adverse 71IU <br /> Determination I V <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete ptuo(to the County only)far the system an paper not ler thu stn a 11 Intent in star <br /> SBD-6398 (R. 05/01) <br />