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Safety and Buildings Division County —� <br /> 201 W. Washington Ave., P.O. Box 7162 Skjet?'e <br /> ICAO f���as Madison, WI 53707 -7162 Site Address <br /> Department of Commerce AS-6 WesF 170&7f 10d. <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision ✓!VJJ ^-� <br /> may be used for seconds ou ses PrivacyLaw, s15.Ml)(m) ✓✓✓✓//// <br /> I. Application Information-Please Print All InformationState Plan I.D. Number <br /> #a 102- 744 <br /> Property Owner's Name Parcel Number - <br /> LA/e,54- /701#1-t-- C4trK ,tiu40P od 8 I an5-U5- U� <br /> Property Owner's Mailing Address Property Location Gov� ? -� <br /> Its-it, LV2Sf 7064.4 �. A ::S �1S— T V0 1N,R /4 E <br /> City,Sate Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> S sen ev W SyBo I lir 63s-- 76do4 <br /> II.Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms p ❑village _ <br /> !71 Pubuc!Co m11ercial-Describe Use &&✓- -eef'F - G�'",�4WkHOC &ownship 56071i� <br /> ❑ Sate Owned Nearest Road <br /> O <br /> IN. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A r� For County use <br /> 1 ❑ New 2 yu Replacement System 3 ❑ R:piacemem oI 6 ❑ Addition to <br /> System I I Tank Only Existing System <br /> B. 11 Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal ase) <br /> 44 Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Gruund 41 ❑ Holding Tank 48❑ Single Pass 51 ❑ Drip Line —� <br /> 45❑ At-Grade 46❑Aerobic Treatment Umt 49❑Recirculating 30❑Other <br /> V. Dispersal/Treatment Area Information: <br /> Design I•low(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rare System Elevation Final Grads <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min.iinch) Elevation <br /> 349p? S,( �`t SU 8 7 �a Ror I?/- <br /> I <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks — <br /> Scptic or Holding Tank 717/6 - 757�Q L�,♦/ s',��¢W <br /> Dosing Chamber /e00 �ee0 1 -Si�ila✓ X <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/MFRS Number Business Phone Number <br /> #ARD ir/S 2.2-5$S 1 7/S- $66- 44 7 <br /> lumber's Address(Street,City,State, Zip'Coae) <br /> 27 7 (o o 14wj 35 <br /> VII . Count /De artment Use Ofily <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing A t i4(ltaApproved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Initial AdverseDetermination v � 0IX. Conditions of ApprovaUReasons for Disapproval, �EcvRos iAuI)IcA APPROW, Fon. A � l <br /> At#ww Pw sixEs .S05r6M 6i'L 26 (, IT& <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 taches in size <br /> SBD-6398 (R. 05101) <br />