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%V Safety and on Ave., Ul P.O. Bo t ounry * <br /> � � 201 W. Washington Ave., . Boz 7162 �u r^n 8 <br /> �sconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce d9lo i j5 4 <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision 479s� <br /> may be used for second purposes PrivacyLaw, 5.04(1)( <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> s ea sr& <br /> Property wner's Marling Address PropeyLocation / a <br /> D/ Now+e Cha/e �d u u;S !O T STov <br /> OW N,R 16 E <br /> City,Stale Zip Code Phone Number Lot Number Bleck Number <br /> Subdivision Name CSM Numbe <br /> U.Type of Building(check all that apply) Daly <br /> 9 1 or 2 Family Dwelling-Number of Bedrooms 3 _ <br /> ❑Village _ <br /> ❑Public/Commercial-Describe Use <br /> 'O'rownship Q/ lel tAto0 <br /> ❑State Owned Nearest Road <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 C New 2 qReplacemcm System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> Sstem Tank Only Existing System <br /> B. I ❑ 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 2111 Mound 47❑ Sand Filter 50❑ Constructed Weiland <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 Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) g1.r Elevation <br /> 11!Iso 6 y� 4�s3 -7 C7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sice[ Fiber PI: clic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /O0o - /DOO .Z S.�n ar X <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation or the POWTS shown on the attached pL:as. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> d.. g&`7 -71s- <br /> Plumber's Address(Street,City.State,Zip Code) <br /> -A7740 re .- 3.f LA-j-e6sYee - <br /> VIII ount /De aliment Use Ont <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing a ignature( 1 ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX.Conditions of Approval/Reasoos for Disapproval <br /> Attach complete plans(to the Coaoty only)for the system on paper nae less than 91/2 s 11 inches in size <br /> S13D-6398 (R. 05/01) <br />