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201 W.Washington Ave.,P.O.Boz 7162 13� n 2 <br /> �seonsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce S or / 7� <br /> Sanitary Permit Application Sanatuy Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 04 0SID <br /> ma be used for Secodary purposes Privacy Law,s15. I)m) ❑ Cluck if Revision <br /> I. Application Information-Please Print All Information state Plan I.D.Number <br /> Property Owner's Name <br /> Parcel Number <br /> Barb w Guile vem as�ee- 0,1q- 306 - 03 6-d0 <br /> Property Owner's Mailing Address <br /> Property l�cadon <br /> 9073 Glwto►i ife G.cn e w� <br /> City,State Zip Code Phone NumberLot Nutrtubez u,S /0 T N.R / <br /> 3 q 4 E <br /> Block Number <br /> ^/t Subdivision Nam <br /> � /CSM Number <br /> IJQUlto /10 <br /> H.Type of Building(check all that apply) //�V"�,rwl' <br /> ,® 1 or 2 Family Dwelling-Number of Bedrooms 3 <br /> OCity <br /> ` <br /> Ovwage <br /> 11Public/CommerDescribeial-Describe Use R1'ownship IZ u C k, <br /> ❑State Owned <br /> Nearest Road <br /> N• Rice Lk <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> stem Tank Onl Eris' S sum <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date 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 Wedand <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(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) u ar <br /> PP `f J.•$ Elevation bq 3 <br /> Oso 643 Avg <br /> s -� hwtr 9� 9y <br /> VI. Tank Info Capacity in Torel Number I Mamtfacturer Prefab site Steel Fiber <br /> Gallons Gallons of Tanks Plastic <br /> New F.xiscng <br /> Co�rete Constructed Glass <br /> Tanks Tanks <br /> Sepdc or Holding Tank /040 _ /0 <br /> e0 y fleet W <br /> 1 C <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. ' <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 2 ZS$S I 715 46- 41S7 <br /> (umber's Address(Stree4 City,State,Zip Co(le) <br /> 2.7-7 :�S �s X48 3 <br /> Coun Department Use <br /> pproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A ent Signature(No Stamps) <br /> ❑ Owner Given Initial Adverse Surcharge Fee) <br /> L-200, co � i�-03 � <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval �C <br /> Attach complete plans(to the Coumy only)for the system on paper not tela than 81/2:11 iucIm la doe <br /> SBD-6398 (R. 05101) ?oN/NG UN�•,r <br />