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Safety and Buildings Division rS�amtary <br /> 201 W. Washington Ave., P.O. Box 7162urnch" <br /> F�scons%n Madison, Wl 53707 -7162 <br /> Department of Commerce _--mitNumber <br /> Sanitary Permit Application p{In accord with Comm 83.21,Wis. Adm. Code, personal information you provide Check Revision J!> /J 7 <br /> may be used for secondary Purposes Prtvac Law. s!5_ (m) $tate Plan I.D. Number <br /> I. Application Information-Please Print All Information <br /> Parcel Number <br /> Property Owner's Name <br /> Tcv's-- �a�/�•forl oat 653d00d700 <br /> Property Location <br /> Property Owner's Mailing Address <br /> 96S Sfhaea Gn. ti . S *AI T qd N, R /6 E <br /> City.State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> rM01441 07 Al 1-1-4`x-7 '7(03. 473 ( <br /> II.Type of Building(check all that apply) ❑City <br /> 2rl or 2 Family Dwelling-Number of Bedrooms �' ❑Village .� <br /> ❑ Public'Commercial -Describe Use CATownship <br /> Nearest Road <br /> ❑ State Owned <br /> /C to Au✓f AC✓S Cf <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 '�New 2 Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank Onlv ExistingSystem — <br /> B. L-1 Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44� tion-Pressurized In-Ground 21❑ Mound 47❑ Sand Filter 50❑ Constructed W edand <br /> 41 ❑ Holding <br /> Tank 48 Ll Single Pass 5151 Drip Lino —� <br /> 22❑ Pressurized In-Ground 8 <br /> 45 L At-Onade 46(_'•Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersal/Treatment Area Information: <br /> Design How(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final <br /> Required Proposed Rate(Gals./Day s/Sq.Ft.) (Min.11nch) <br /> 30Prefab Site Steel Fiber Plastic <br /> VI.Tank Info Capacity in Toral Number Manufacturer <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing _ <br /> Tanks Tanks dd <br /> Septic or Holding Tank 4�100 - p�0 <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume respomilidity ror installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) <br /> Plumber's Si¢namre MP/MFRS Number mo <br /> 6�aev ,�/s �- 22S$ S 1 lumber's Address(Street,City,State, ZipCode) <br /> 2-77too 14w `�'S ;`B ,VIII. Count /De artment Use 1Salutary Permit Fee(includes Groundwater Date IssupsiApproved ❑ Disapproved Surcharge Fee) 1❑ owner GizJl�r <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete Plato(to the County only)for the system on paper not Iess than 81/2 x 11 Inches is size <br /> SBD-6398 (R. 05101) <br />