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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 <br /> iTiseonsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number J <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide kk�Check if Revision Ll/�U 9t; <br /> may be used for secondary purpose s Privacy Law,s15. 1 m <br /> I. Application Information-Please Print All Information .0 State Plan I.D. Number <br /> of 1 Property Owner's Name � <br /> i Parcel Number f, <br /> Property Owne 's Mailing Address y Property Location <br /> -75-16/Y/ f e, / k �:S Z6 T /-/0 N,R /J <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> L. <br /> Subdivision Name CSM Number <br /> h19 lG ,a/ IYAJ 6 3� �1�3 Y7 - /5'o U. l y 7 <br /> II.Typi of Building(check all that apply) ❑City <br /> 9 1 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> I <br /> ❑Public/Commercial-Describe Use Rrownship ap <br /> ❑State Owned Nearest Road t <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 13 ❑ Replacement of 6 ❑ Addition to For County use <br /> stem Tank Only Existing Sys <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 211) Mound 47❑ Sand Filter 50❑ Constructed Wetland i <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 3o❑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 /> X00 _ eqs <br /> /ZL96 1,2C16 . 7 9'79 /Cog <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 <br /> Dosing Chamber <br /> rC <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 /> cRoev n/s Z 2S$S I 715- g66- 4157 <br /> lumber's Address(Street,City,Stare,Zip Code) <br /> 27 7 (o 0 14w 55 U6am -54'513 <br /> VIII. Count /De artment Use Ofily <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Sig tune o Stamps) <br /> ❑ Approved El Disapproved <br /> Surcharge Fee) _ - <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> fir 0, <br /> Attach complete plana(to the County only)for the system on paper not less tlun 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br />