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Safety and Buildings Division County L <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> yDepar!:tm�ent <br /> onsin Madison, WI 53707 -7162 Siu Address <br /> of Commerce 271174 nroe L <br /> Sanitary Permit Number <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide ❑ Check if Revision <br /> may be used for secondary ses Privac Law, 5.040)(m) State Plan I.D. Number <br /> 1. Application Information-Please Print All Information n a-7o� —n/ 4 fN <br /> Property Owner's Name Parcel Number / lO <br /> J0 N property Location oO <br /> Property Owner's'�V�MAAailrring Address <br /> A <br /> , ntA1C <br /> '(� <br /> City,State Zip Code Phone Number Lot r Block Number <br /> C' 7V`�-c �.OT �' <br /> , <br /> Subdivision Name CSM Number <br /> S tqg 7/5 — 7B 96 <br /> 11.Type of Building(check all that apply) ❑City <br /> X1 or 2 Family Dwelling-Number of Bedrooms 3 []village <br /> ❑ Public/Commercial-Describe Use 19township <br /> ❑State Owned Nearest Road <br /> Ule <br /> atNAJ42r5L <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> For County use <br /> A. 1 X New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank()niv Exisdn S sum <br /> Permit Number Dau Issued <br /> B. C1Check if Sanitary Permit Previously Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 210 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 <br /> 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> R' aired Proposed Rate(Ga1s./Days/Sq.Ft.) (Min./Inch) Elevation <br /> o RZ lelz <br /> VI.Tank Info Capacity in 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 '� - ��W <br /> Dosing Chamber 900 <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Name(Print) II <br /> t�� <br /> G�flR-P /W_S <br /> lumber's Address(Street,City,State,Zip Code) <br /> -2-7-7 o 14w 315 ABsrm �4$ 3 <br /> VIII. Count /De artment Use I <br /> San tary Per it Fee(includes Ground ter Date Issued Issuing Agent Signature S <br /> pproved ❑ Disapproved Surcharge F <br /> ❑ Owner Given Iridal Adverse v <br /> Determination ' <br /> I <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br />