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Safety and Buildings Division County -I <br /> iseonsin 201 W. Washington Ave.,P.O.Boz 7162 &f Nei•f <br /> Madison, WI 53707 -7162 Site Address <br /> De artment of commerce rev- j(` <br /> t <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ya37 7 X/ <br /> may be used for secondary purposes Privacy Law,sl5. 1 m ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number 1-,nProperty Owner's Name State <br /> `LTJ' <br /> Pael Number <br /> Re4 C,lo 01:z g7s-v 04 lop <br /> Property Owners Mailing Address Property Location /�^ <br /> 9 -' I#Cifb T a ti;S T N.R /J <br /> City,State Zip Code Phone Number Lot Nu ber Block Number <br /> Subdivision Name CSM Number <br /> �vf Ge�ro Kiv '37f 36Z 715 29556 wl- S nA✓tis Anv-M V✓. <br /> II.Type of Building(check all that apply) ❑City <br /> I or 2 Family Dwelling-Number of Bedrooms 3 ❑Village <br /> ❑ Public/Commercial-Describe Use p )�'I' <br /> ownshi �So^j <br /> ❑State Owned Nearest Road <br /> fifree /h-/� <br /> M.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> �' 1 Y New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> AT <br /> Tank Onl Exis' S stem <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Non-Pressurized In-Ground 210 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 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Anes Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) 7� �y.Z Elevation <br /> 60 6 y3 67g • -7 do*m Q3.� IRK- <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 Tank / 00 /9VO / <br /> Dosing Chamber vWW <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/MFRS Number Business Phone Number <br /> -im ev d-s 2 ZS$S I 1 46- 4157 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2-7- oo f+w 35 , X447 3 <br /> Cotmt /De artment Use Oftly <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu' Agen Signature(No Stamps) <br /> Surcharge Fee) <br /> 11Owner Given Initial Adverse �1 tai q_I I/e <br /> Determination IJV <br /> IX. Conditions isapproval <br /> t <br /> 15 2003 <br /> A�hC (to the County only)for the system on paper not less than SV2 x 11 Inches in size <br /> BURNEI <br /> SBD-6398 (R. 05/OgQNING <br />