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Safety and Buildings Division County �� <br /> Visconsin <br /> 201 W. Washington Ave.,P.O.Box 7162 I jrte//Madison, WI 53707 -7162 Site Address <br /> De artment of Commerce 90 <br /> Sanitary Permit Application Sanitary Permit Number �a <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> may be used for secondary purposes Privacy Law,sl5. 1 m <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Prope Owner's Name Parcel Number <br /> Property Ow 's Mailing Adftress Property Location <br /> J 'A S T / N,R/S <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> LL S~flY./.3 t ) 71, ���/ 3�5� Subdivision Name CSM Number <br /> / <br /> II.Type of Building(check all that apply) <br /> ❑City <br /> PTor 2 Family Dwelling-Number of Bedrooms <br /> ❑Village <br /> ❑Public/Commercial-Describe Use <br /> Township SW✓./J <br /> ❑State Owned Ne st Road <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 11 Replacement of 6 El Addition to For County use <br /> S stem Tank Only Exis' S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Typo Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 on-Pressurized In-Ground 2111 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 /> 30o y�gjcT0 7 1 7.,-, s- <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 75 '9 _ �sol�- <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 /> .V//�cceT Be_nlZ)'It a� rirr <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved SanitaryPermit a(includes Groundwater Date Issued Issuing Agent Si rare( Stamps) <br /> Surcharge O <br /> ❑ Owner Given Initial Adverse <br /> Determination l �(/ <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete pians(to the County only)for the system on paper not less than 81/2 x 11 rhes in size <br /> SBD-6398 (R. 05101) <br />