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1.01 W. WashingtonAve., P.O. Box 7162 1 ecii-A <br /> Wisconsin Madison, WT 53707 -7162 1 Site Address <br /> Department of Commerce I 333 <br /> Sanitary Permit Application I Suutary Permit Number 1 <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide 'r^ <br /> may be used for sero purposes Privacy Law. 15.04(1)m) ❑ Check if Revision <br /> I. 3 7"l/ Q� <br /> Application Information-Please Print All Information 7 Stam Plan I.D. Number v <br /> Property Owrieerr''s Name / <br /> 7a J i Patce!dumber i <br /> 11 <br /> Property Owner's G s Mailing Address O'O `r / 35 Q- 0500 I <br /> Property Location <br /> 333 Ma ow Green Ln. k/ <br /> City,Stam Zip Cade Phone Number % �:S 7 T d/O N.R /N E <br /> Lot Number Block Number <br /> I <br /> Subdivision Name CSAI Number <br /> UAW are tv S-7�e'3a <br /> H.Type of Building(check all that apply) V.U <br /> ❑ 1 or 2 Family Dwelling (]city <br /> ung-Number of Bedrooms <br /> ❑ Public/Commercial-Describe Use ❑Village <br /> ❑Stam Owned Rrownship S6e7`7` <br /> Nearest Road I <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). ComplmeaAakl ete line B if applicable) <br /> n l h. <br /> A. I ❑ Few 2 larstneat <br /> �P 3 ❑ Replacement of 6 ❑ Addition m For Cotmty me <br /> stem Tank Oal S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dam Issuted <br /> IV.Type of Permit: (Check all that apply)(aumbering scheme is for internal use) <br /> 44 W Non-Pressurized InGrom d 2111 Mound 47❑ Said Filter 50❑ Constructed Wetland <br /> 22❑ Pmssttrized In-Ground 41 ❑ Holding Tank 48❑Single Pass 51❑Drip Line <br /> 45❑ At-Grade 46❑Aembic Treatment Unit 49❑Recirculating 30 Cl Other <br /> V.D' tmeat Area Information• <br /> Design Flow(gpd) Dispersal Area 7Tot�alNumber <br /> Required Soil Application Perooladon Ram System Elevation Final Grade <br /> Rate(Gals./Days/Sq.Ft) (Min./Imch) j <br /> 300 605 Elevation <br /> 93.E VI.Tank Info Capacity in Man facturer Prefab Site Steel Fiber IGallons ' Plastic <br /> Nom, i Concrete Constructed Glass <br /> Tants Tama <br /> Septic or Holding Ta ik <br /> Dosing Chamber <br /> I i i <br /> VII.Responsibility Statement- I,the undersigned,assume respousibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signs aue MP/MPRS Number <br /> - Busitxss Phone Number <br /> � aev ,e�r/s z2S$S 71�= g66- 4157 <br /> (umbels Address(Street city.stain.Zip code) <br /> 27 7 (a o <br /> artment Use v <br /> i <br /> !7i <br /> Disapproved Sanitary Permit Fee(includes Groundwater Dam Issued <br /> Surcharge Fee) �m�g a igmamre rtio s) <br /> Owner Given Iridal Adverse <br /> y+Man <br /> UC. Conditions of ApprovaUReasotns for Disapproval Vu <br /> i <br /> I <br /> I <br /> i <br /> Attach wmplete plans(to the Comity ool>')for the system on paper net lea than 81/2 c 11, in rite i <br /> SBD-6398 (R. 05101) <br />