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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 4tr rylrekt l <br /> ` ,iseonsin Madison,WI 53707-7162 Sim Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Pe it Numher <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ,Ut�0/ <br /> may be used for secondarypurposes PrivacyLaw,s15. 1 m ❑ Cbec iTRevtsion / <br /> I. Application Information-Please Print All Information State Plan I.D.Number (�l( <br /> Property Owner's Name Parcel Number " <br /> &V lZ Ai70 oZ je o v1 <br /> Property Owner's Mailings Property Location <br /> 765- yQ <br /> 7or �/ -4 / b %;S T 'yO N,R � - <br /> City,State Zip Cade Phone Number Lot umbeBlock Number <br /> 4 1A <br /> S"visiowName CSM Number <br /> .l� ti 5-5467 07 663- 7Z-11L <br /> II.Type of Building(check all that apply) ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms Z <br /> ❑Village <br /> ❑Public/Commercial-Describe Use Township p elo� <br /> ❑ State Owned Nearest Road <br /> M.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 R1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Additionto For County use <br /> Sy stem I I Tank Only Existing System <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 rise) <br /> 44 Nan-Pressurized In-Ground 210 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 Sod Application Percolation Rate ystem El ation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) 3q4Elevron <br /> 13.36 s.cat <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> Newj Existing <br /> Tanks Tanks <br /> Scptic or Holding Tank <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Priv[) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ��kev ,�s - zzs$s i 7 rs- gra- q�s? <br /> lumber's Address(Street,City,State,Zip Code) <br /> z7 7 !o o i4w 35 a6BgE& , i4$ 3 <br /> VIII. Count /De artment Use 1 <br /> Approved ❑ Disapproved <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Apar Si re mps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverseo2Q�, /�/96 Z� <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disap roval <br /> g <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. 05101) <br />