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Safety and Buildings mvision t:ounty <br /> M 201 W. Washington Ave., P.O. Box 7162 v 6LN E7r <br /> w omiseonsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide El Check if Revision <br /> may be used for secondarypurposes PrivacyLaw,115. 1 (m) / <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> o cjt Diy as 33 0/ ao� <br /> Property Owner's Mailing Address Property Location <br /> lt <br /> (, `t$ t <br /> 0 0104 St � � tNLt, AVFtc:s33T38N,RrS `V <br /> City,State Zip Cock Phone Number Lot Number Block Number <br /> Nu Sft/t q 5 M of. SS� 3 3 65-1 L1,37 1{,7 y Subdivision Name CSM Numbe <br /> U.Type of Building(check all that apply) ❑City <br /> 01 or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village <br /> ❑Public/Commercial-Describe Use RI'ownship L q 'C'o Ile-Fl,a <br /> ❑State Owned Nearest Road <br /> le 5 ej <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal use). Complete line B if applicablt:) <br /> A. <br /> 10-New 2 ❑ Replacement System 3 ❑ �Rcp�lacemcnt of 6 ❑ Addition to For County use <br /> System Tank Existin S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.ff77Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Q-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. Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> 1/ 5-0 <br /> Required �yf Proposed4 Rate(Gals./Days/Sq.Ft.) (Min./Inch) Ele�vvaaioon <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Sicel Fiber Pl;;aie <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New I Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank _ /V 00 r / CSCC X <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached ph ns. <br /> Plumber's Name(Print) Signature PRS Numbcr Business Phon.Number <br /> DAA 2Plu is 0cN ( aa3y�iy ��s63ss00)L <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 5_S6 '9 64eswick 00 _ 5pooljE12 AJj:7 5-gVo <br /> VII . Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing o ignature o Stan ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse �. <br /> Deterntinadon iC �C/ fi7 JUtbL 0 <br /> IX. Conditions of Approval -o-us for Disapproval <br /> Attach complete plus(to the County only)for the system on paper not less than 8112 x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />