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Safety and Buildings Division County <br /> NVisconsin <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> Madison,WI 53707-7162 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application SanitarPermit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide `� 3 7S <br /> may be used for secondary purposes Privacy Law,s15. 1 m ❑ Check if Revision <br /> I. Application Information-Please Print All inforjqation � ��3 oZ State Plan I.D.Number <br /> Property Owner's Name Parcel <br /> azi Oil D� goo <br /> PropeK Owner' 'ing Address Property Location ' <br /> L % 'A;S T N,R1 <br /> City,State Zip Code Phone Number Lot N ber Block Number <br /> Walt' `jam �' � jIS_/��Lr" jj 10 Subdivision Name CSM Number <br /> is ,-Vfg tll� V. <br /> II.Type of Building(check all that apply) ❑City <br /> X1 or 2 Family Dwelling-Number of Bedrooms 2 []Village <br /> ❑Public/Commercial-Describe Use ownship scott <br /> ❑State Owned Nearest oad g <br /> l Lg(JQ� <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 eplacement System 3 ❑ Replacement of 6 ❑ Addition to For County nue <br /> System I Tank Only Existing System <br /> B. 11Check 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 21AMound 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 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(Gds.lDays/Sq.Ft.) (Min./Inch) Elevation <br /> VI.Tank Info Capacityin 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 C/y� <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 Pbone Number <br /> c�wp ir/s 22SS S 715S66- 41 77 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2.7-7 &0 35 <br /> VIII. Cormt /De artment Use Ofily <br /> Approved ❑ Disapproved <br /> Sanitary Permit Fee(includes Groundwater Date Issued I ent Signatu (No Stamps) <br /> SurF ge Fee) <br /> ❑ Owner Given Initial Adverse //�l <br /> Determination �• v V <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Qpiq 2 3 <br /> R STr <br /> 2 COUM <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches It size <br /> SBD-6398 (R. 05101) <br />