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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O. Box 7162 i <br /> Visconsin Madison,wI 53707-7162 Site A dress n <br /> De artment of commerce /�1Y+ <br /> Sanitary7i� <br /> it Num r <br /> Salutary Permit Application 3 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Checevision <br /> may be used for sero Purposes Privac Law,s15. 1 m PPanumbe <br /> I. Application Information-Please Print All Information 2 a�g <br /> Property Owner's Name ✓s- J -Property Owner's Mailing Addressnom,;S �o T N,R <br /> City,State Zip Code ;Phone Number Block Number <br /> 55024 - X3.767 IlSu vnsion Name ' CSM Number <br /> KRXxVi,v�ronl, MN- 1/ I�p. a � <br /> II.Type of Building(check all that apply) gg ❑city <br /> ;K1 or 2 Family Dwelling-Number of Bedrooms 7 ❑Village <br /> ❑Public/Commercial-Describe Use wnship - <br /> ❑State Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> For County use <br /> A <br /> IoNew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> sue <br /> IV.Type of Permit: (Check all that ap )(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 22L&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.Dig ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevarion Final Grade <br /> Re fired Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inuh) Elevation <br /> 9g, 73Prefab site � <br /> VI.Tank Steel Info Capacity in Total Number Manufacturer Concrete Constructed Fiber <br /> amass Plastic <br /> Gallons Gallons of Tanks <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 0 /DEQ <br /> Dosing Chamber 601 �QQ <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 /> �#ROzv ,JS - 22S$S 1 71.E `b66- q-1S? i <br /> lumber's Address(Street,City.State,Zip Code) <br /> 27-7 !o n /-}w 35 LA/f@AY <br /> A �4g 3 <br /> VIII. ount /De artment Use Ofily <br /> Sanitary Pe 't Fee(includes Groundwater Date Issued Issu' g gent S' na ( Stamps) <br /> pproved ❑ Disapproved Surcharge <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)ror the system on paper not less then 81/2 x 31 Inches in size <br /> SBD-6398 (R. 05101) <br />