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Safety and Buildings Division County —� <br /> 20i W. Washington Ave., P.O. Box 7162 Qurn '1_ <br /> G <br /> i iseonsin Madison, WI 53707 -7162 Site Address n <br /> Department of Commerce <br /> Sanitary Permit Application Sana"Permit Number <br /> In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision - 1<1� t V <br /> may be used for secondarypurposes PrivacyLaw, s 5.040)(m) <br /> I. Application Information-Please Print All Information w Sate Plan I.D. Number <br /> c0• d <br /> Property Owner's Name p Parcel Number <br /> P,ft, ( OeAvanoC 04 4(kf3 �of900 <br /> -Property Mailing Address Property Location <br /> 6bv,E-t.oi 1 <br /> all t 7d�- 4,S7-11 /9✓e 'A 'A:S / TOO N, R IS- <br /> City, <br /> SCity,State Zip Code Phone Number Lot Nuptber Block Number <br /> Subdivision Name CSM Number <br /> S>`u✓ {�n.,i i W1' S 'r0�6 &ITO-0.336 /„' <br /> M Q3 <br /> II. Type of Building(check all that apply) []City <br /> ZI or'-Family Dwelling-Number of Bedrooms tT ❑Village <br /> ❑ Pubiic.'Commercial -Describe Use <br /> Township t,�Ack'Sen <br /> ❑ State Owned Nearest Road //�� n <br /> a/—; e <br /> !H. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. r- <br /> 1 .� New 2 �►(Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Only ExistinE 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 use) <br /> 44X1 Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Welland <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 I•low(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min.)lnch) 93 Elevation <br /> Sod _ 9� / <br /> y}�7 43r '7 9/• 7 9y. -7 <br /> VI.Tattk Info Capacity in Total Number Manufacture,- 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 /> 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.c;vnartrre MP/MPRS Number Business Phone Number <br /> e-im v /r/S /�- •�� 2ZS$S � 7�S- g66- q-1S7 <br /> lumber's Address(Street,City,State,Zip�Code) <br /> 27 7 (a o 14,vv�j eB _54S 3 <br /> VU1, County/Department Use Ofily <br /> 169�Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin gent na (N amps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse 7G�l 9 <br /> Determination �,/(�' 'S'7 O <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less than 81/2 x 11 tithes in size <br /> SBD-6398 (R. 05101) <br />