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Safety and Buildings Lilvislon county <br /> WAN 201 W. Washington Ave., P.O. Box 7162 91f f-W G <br /> isconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit"a"he` <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> my be used for secondary Purposes Privacy Law,s15. 1)(m / tr <br /> I. Application Information-Please Print All Infos�ion State Plan I.D.Number <br /> C:C)l ( g1 # a4 g /0767 <br /> Property Owner's Name Parcel Number <br /> 44M6 er.0Z 7Ce- Dab- iHa -al-oao <br /> Property Owner's Mad' Address Property Location - <br /> oS 3 77G A rdw u 'Jt'u:S V/ T7el N. R J7 E <br /> City.Sate Zip Code Phone Number Lot Number Black Number <br /> Sabd rmamidame CSM Numtx � <br /> $ ooN er w� Syc�/ d, /y 7y <br /> II.Type of Building(check all that apply) ❑City <br /> i <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms - <br /> /� []Village _ <br /> 9PubliclCommercial-Describe Use ! A> iffTownship 5c- <br /> 0 <br /> G❑Sate Owned Nearest Road <br /> C <br /> III.Type of Permit: (Check only one box on line A (numbering scheme forinternal use). Complete line B if applicable) <br /> A ❑ New 2 Replacement System 3 C1 Replacement of 6 ❑ Addition to For County use <br /> S stem Gor1sK✓f�.+ag ({.7 Tank OnlyExistingSystem <br /> B.]�O 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 210 Mound 47❑ Sand Filter 50❑ Constructed Wedind <br /> 22❑ Pressurized In-Ground 41KHolding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dir ersal/Treatment Area Information: <br /> Design flow(gpd) Dispersal Area Dispersal Arca Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sicel Fiber Plx.;[ie <br /> / Gallons Gallons of Tanks Concrete Constructed Glass <br /> t New Existing <br /> Tanks I Tanks <br /> Sapti mat Holding Tank — W <br /> Dosing Chamber O� <br /> VU. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plmos. <br /> Plumber's Name(Pr t) Plumber's Sigmmre MP/MPRS Number Business Phon.:Number <br /> Plumber's Address(Street,City,Sure,Zip Code) <br /> 7Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin ent igNNre tan Ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> LX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 61/T x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />