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Safety and Bmlaings invasion t:ounty <br /> ter 201 W. Washington Ave.,P.O.Box 7162 u T <br /> `�sconsin Madison,WI 53701-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.2 1.Wis.Adm.Code.personal information you provide ❑ Check if Revision <br /> may be used for secondary purposes Privacy Law,s15. 1)(m <br /> I. Application Information-Please Print All Info tion State Plan I.D.Number <br /> o - a��9 /076P787 <br /> Property Owner's Name (nParcel Number <br /> G� fNIs Pg1"V1 ,0*1 O/8r90-25r 0 26 c <br /> Property Owner's Mailing Address Property location <br /> 5635 'A /r W7f} 'Au:S.24 T37N,R/U E <br /> City,State Zip Code Phone Number Lot Number Blcck Number <br /> / Subdivision Name CSM Numbe 9b <br /> .4 /k,- �4,, .v C?S ..D <br /> H.Type of Building(check all that apply) ❑City <br /> J211 or 2 Family Dwelling-Number of Bedrooms 3 ❑village _ <br /> ❑Public/Commercial-Describe Use <br /> wnship <br /> ❑State Owned Nearest Roads <br /> ;J—cs 4✓ov <br /> IIT.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 ❑ New 2 5LReplacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Onl Existin System <br /> B. Check if Sanitary Permit Previously Issued Permit Number Q Date Issued — I Y <br /> 126t <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❑ Constructcd Wcdand <br /> 22❑ Pressurized In-Ground 41 gHolding 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 Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> '1 -o <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site S1 cel Fiber PI Mc <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> 24W"r Holding Tank <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached pltdis. <br /> Plumber's Name p(Pint) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> �� , z :;__ 9V <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �- <br /> VIII County/De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued issuing en ignatur Stall ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse 30OP I O j A,i <br /> Determination / U4 <br /> IX. Conditions of Approval/Reasous for Disapproval JL J <br /> hdaow� TANkS MM)M* Roos Axv del .Gbe�at: � O 1F 4XA04 iA) )4 -a00 � CAT arc <br /> 956, <br /> Attach complete plans(to the County only)for the system on paper not less than 8112%11 inches to size <br /> SBD-6398 (R. 05/01) <br />