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isconsin <br /> :Madison.WI 53707-7162 Site Address <br /> Department of Commerce 3193 QLk <br /> / 0. <br /> Salutary Permit Application ( -Sammry P`UnIt"°mgr � <br /> In accord with Comm 83.21,Wis.Adm. Code,petsoml information you provide <br /> tns be used for SecodarY ses Privacv Law,s15. 11 ml Check if Revision 3 0,3I. Application Information—Please print All Information <br /> State Plan I.D. Number <br /> Property Owner's Name <br /> Parcel Number <br /> Char/t!5 //o '�`�(� 0/d, — 1( 61(— a/8,00 a. <br /> Property Owner's Mailing Address <br /> P[vperry I.ocadan <br /> Ciry,StadeZip Code Phone Number I Lot umber W 4 S ,Block Number R /S' <br /> I <br /> Subdivision Name CSM Number <br /> G yawn P�: I"A/. �f63b7 �1q-- 663-360 <br /> 11.Type of Building(check all that apply) <br /> 0 1 or 2 FamilyDwell' ❑Ciry <br /> Dwelling-Number of Bedrooms <br /> ❑Public/Commercial-Describe Use <br /> ❑village <br /> ❑State Owned Rrowtuhip JQ Gk50h <br /> Nearest Road <br /> III.Type of Permit: (Check only one box on line A num Lin L k R�, <br /> (numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 ❑ New 2 <br /> Replaceaent System 3 ❑ Replacement of 6 ❑ Addition to For County we <br /> stem Tank Oni S stem <br /> B• ❑ Check if Sanitary Permit Previously Issued Pew Number Dare Issued <br /> IV.Type of Permit: (Check all that apply)(mmmbering scheme is for internal[are) <br /> 44 Z Non-Pressurized In-Ground 210 Mound 47❑ SAW Filter 50 Q Constructed Wetland <br /> 22❑ Pressurized In-Ground 41❑ Holding Tank 48❑Single Pass 51❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treaur=Unit 49❑Recitenla'ng 30❑Other <br /> V <br /> . tment Area Information• <br /> I <br /> Dispersal Ana Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(GaIsMays/Sq.Ft.) (,NIin./Inch) IIevation <br /> Capacity in Total Number Manufacturer prefab site Steel Fiber <br /> Gallons Gallons of Tanks Plastic <br /> New Concrete Constructed Glass <br /> Tads Tattle <br /> Septic or Hotditta Tank /000 - /Oo01 <br /> Z WrwPsco <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume rapom>biliq,far installation of the POWTS shown on the attached�g-ma. ! <br /> Plumber's Name(Print) Plumber s Signature MP/MPRS Number <br /> Business Phone Number <br /> e- -P 22519 S I g66- 4157 <br /> lumber's Address(Street,Ciry�I,JlState,Zip Cade) <br /> 2.77 &0 TT'W �S �$ <br /> Cotm /De rot Use Offly <br /> pproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing gnamr_t tis) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse '1/p� /t j <br /> Determination OSW•z <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> i <br /> Auaah mmplete plans tw the County ody)for the system oa <br /> paper not teas than 81/2 c 11 toeha in size <br /> SBD-6398 (R. 05/01) <br />