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Safety and Buildings Division County <br /> an 201 W. Washington Ave., P.O. Box 7162 19,4 0,U e___11►seonsin Madison,WI 53707 -7162 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Per Number ? <br /> In accord with Comm 83.21, Wis.Adm. Code,personal information you provide ❑ Check if Revision <br /> my be used for xco2dag purposes Privacy Law 15. 1 m <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> C 3a o <br /> Property Owner's Mailing Addressr � ' Property Location <br /> r / <br /> pZ 6 W r �/N/U Q/7/��A' pkwy frrtJ <br /> l.J tR 46:S l T !0 N. RI_S E <br /> City, State Zip Code Phone Number Lot Number Block Number <br /> LS OO/7 Subdivision Name CSM Number <br /> r 7 J <br /> 11 T 3 <br /> ype of Building(check all that apply) ¢ ❑City <br /> or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village <br /> ❑Public/Commercial-Describe Use <br /> owwhipS G <br /> ❑State Owned Nearest Road <br /> 37y3 <br /> /lye e!S _ <br /> III. Type of Permit: (Check only one box on fine A (numbering scheme for internal use). Complete line B if applicable) <br /> A' t ❑ New 2 Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Talc Onl ExistingS stem <br /> B. ❑ Check if Sanitary Pernsit Previously Issued Permit Number Dam Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 p -Non-Pressurized In-Ground 21❑ Mound 47 11 Sand Filter 50 El 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(bpd) Dispersal Area Dispersal Area Soil Application Percolation Ram System Elevation Final Crude <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 1+50 750 750 5 0 - 6 0 9g. <br /> VI. Tank Info Capacity in 1 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 <br /> Dosing Chamber loon, <br /> , <br /> MN <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pfjpt) Plumber's Signature MP/MFRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 0031 J �j� •S�!/' e..J lri✓ 8-71 <br /> VIII. Count Department Use Only <br /> )OPApproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu7A [Si ture n <br /> �( ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse gA � - <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval I G t' Eq� VV <br /> �J <br /> AUG 2 ? 205 Lb) <br /> Attach complete pew(to the County an for the rynem let I Ilicyn,in size <br /> ZONING <br /> SBD-6398 (R. 05101) <br />