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Safety and Buildings Division County <br /> N. VA 201 W. Washington Ave., P.O.Box 7162 40 <br /> lseonsin Madison,WI $3707 -7162 Site Address Ssr�2 r.11 <br /> Department of Commerce 5-380 &4,64 IN*V Pb sdf871 <br /> Sanitary Permit Application Sanitary Permit Number (1 <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide, 3 <br /> may be used for secondarypurposes PrivacyLaw,sl5. 1 m ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Pro, Owner's Name Parcel Number <br /> T C l� U rt�o'ta�a O 31Qo <br /> Property Owner's Mailing Address Property Location <br /> t9! /a" 'j (JCr u•�,(��. lad I 'A S T 39 N,R /5- <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> p <br /> H.Type of Building(check all that apply) +� ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms []Village r <br /> ❑`Public/Commercial-Describe Use Vy+ownship C14 ���L�J7C- <br /> ❑State Owned C (� Cr b Nearest Road <br /> III.Type of Per . (Check only one box on e A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 NCNew 2Replacement System 3 IJReplacement of 6 El Addition to For County use <br /> System Tank OnlyExis' System <br /> B. [I 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)9,kZon-Pressurized In-Ground 20 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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) Elevation <br /> �o0 4aa �3� 17 <br /> VI.Tank in Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks LB !t[6r�- <br /> Septic or Holding Tank _ ' �alt <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) 1 PI gnatme MP/MPRS Number Business Phone Number <br /> on�A�1� cpolz^!r ':2 i 4�4-7 u -7<S- '2(/L/ 35 0 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 16-71 3 .S. .5 r-,O t p �S !)+4 1�3u r-c ��r 5 (-C& -Lo <br /> VIII. Cotmt /De artment Use Onl <br /> e-j&provednun ❑ Disapproved Sanitary Permit Fee(includes G ater Date Issued Issuing Agent in (N S ps) <br /> Surcharge Fee) �} <br /> ❑ Owner Given Initial Adverse �� I Q/Z$l6 <br /> Determination <br /> EK. Conditions of Approval/Reasons for Disapproval <br /> del i5 d� a s�s�>r, P,( �, ��`3`I <br /> j <br /> elasek on T>*3 e&9 �S <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. 05/01) 2ON7N((O�N <br />