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r 201 W. WashingtonAve ,• P.O. Box 7162 <br /> i�sevnsin Madison.WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Penmt Number /� <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 39 3 3 3 <br /> ma be used for secondarys Priv Law,s15. 1)(m) C3 Check if Revision <br /> 1. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name <br /> 'W <br /> Parcel Number <br /> Lena Noq,erbrmk ' c;) ��CD 0d0 - <br /> Property Owner's Mailing Address <br /> p / Property Location <br /> u st 'A,S. /9 T 4/0 N.R /(O <br /> City,Stare Zip Code Phone Number Lot Number <br /> Block Number <br /> Gwt/ii# 3 3 <br /> Subdivision Name CSM Number <br /> Ce041, W 7 .S`�fl��y yrs- 6`F!o-99/6 I-of6 Jtnsens tAkesA.�c 0,'v_ <br /> II.Type of Building(check all that apply) <br /> ❑City <br /> .®,-1 or Z Family Dwelling-Number of Bedrooms <br /> 11Public/Commreial-Describe Use <br /> ❑Village <br /> ❑State Owned OTownship 6,9 GQ <br /> Nearest Road <br /> Gu. ad, U, <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal ruse). Complete line B if applicable) <br /> A. 1 X New 2 ❑ Replacement System 3 ❑ For Co use <br /> Replacement of 6 ❑ Addition m qty' <br /> stem Tank Onl Eris' S stem <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 rue) <br /> 44,K Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-,round 41❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46 C1Aerobic Treatment Unit 49 C1Recimtlating 30 11Other <br /> V.Dispersal/Treatment Area Information: <br /> i <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation, Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 3G0 � 3� �G� , r — 7d 96. s- <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber I Plastic <br /> Gallons Gallons of Tanks Concrete Constructed I Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank SiDO _ *210 <br /> �o x <br /> Dosing Clamber <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 /> �ffiRa2v ��s 2�S$lumber's Address 866- 4157 <br /> (Street,City,Stare,Zip Code) <br /> 277 &0 144 �S �gI , <br /> Corm /Department Use Ohly gm <br /> Approved ❑ Disapproved Sanitary Penrut Fee(includes Groundwater M, l,,,,ued Issuing en igna o Stamps) <br /> Surcharge F I 1) <br /> ❑ Owner Given Initial Adverse Determination U`1 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> V <br /> B 466' <br /> Attach complete plans(to the Canty ody)for the system on paper not leas than 8112 x 11 Inches <br /> SBD-6398 (R. 05101) ��n6~`A � <br />