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` Safe and Buildings Division County <br /> 201 W. Washington Ave., P.O.Box 7162 Au �(/"e <br /> isconsi►n Madison, WI 53707-7162 Site Address <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 q k'3 7/ 9 p 7 <br /> may be used for Seco ses PrivacyLaw,s15. 1 m ❑ C ec of Revision / <br /> I. Application Information-Please Print All Information State Plan I.D.N r <br /> Property Owner's Name <br /> nn Patul Ntlmbor <br /> 5aa <br /> PropertyOwner's Mailing Address <br /> /� Properg�Location C <br /> 6 G CC /r'1 li .'A:S3 Ty N.R 6l� <br /> City,State Zip Code Phone Number Lot Number <br /> Nn��/ num y ��� L 41Block Number <br /> tf 5-q�,70 �/5 Subdivision Name um <br /> lX6 7`5 13z 61-19 <br /> II.Type of Building(check allthat apply) <br /> 1 or 2 Family Dwelling-Number of Bedrooms ❑City <br /> ❑Public/Commercial-Describe Use ❑Village <br /> ❑State Owned Township Al' (' S <br /> Nearest Road 1 <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1,KNew ECOIReplacernent <br /> 3 ❑ Replacement of 6 ❑ Addition to For County useS sum Tank OnlB- ❑ Check if Sasued Permit Number Date Issued <br /> lv.Type of Permit: (Check all that apply)(numbering scheme is for internal nue) <br /> 44,,d Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wedand <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.Dis ersal/Treatment 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 <br /> X50 9oa 9 33 , 5 <br /> 92 95 ss- 97 <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 /> de Holding Tank Oo <br /> Dosing Chamber le <br /> Z�CrGv <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu is ignamre MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) 715 <br /> ZZ <br /> 7/ <br /> VIII. Count /Department Use Orel <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature s <br /> Surcharge-Nee) / <br /> ❑ Owner Given Initial Adverse /) Mt\ C 3/7 f,a3 <br /> Determination �C(A) lJ <br /> IIC. Conditions of Approval/Reasons for Disapproval <br /> Attach complete pians(to the County only)for the system on paper not Iw than 911 .c 11 iocbc b size <br /> SBD-6398 (R. 05101) <br />