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Safety and Buildings Division County <br /> NVisconsin <br /> 201 W. Washington Ave.,P.O. Box 7162 44 rAJ Madison,WI 53707 -7162 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary <br /> anitaPermit Number R <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Ch k if Revision� <br /> may be used for secondarypurposes Privac Law, 5. 1 m <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Y <br /> Property Owner's Name Parcel umber <br /> B."// wd fiefs o�6 � 6 a <br /> Property Owner's Mailing Address Property Location PC_ G, i <br /> t / <br /> �J6 / /V OU/, /^• !�/. S I T3? N,Rt7 E <br /> City,State Zip Code Phone Number Lot N ber Block Number <br /> Subdiv sion Name CSM Number <br /> EA /v <br /> II.Type of Building(check all that apply) ❑City <br /> or 2 Family Dwelling-Number of Bedrooms <br /> _ ❑villa ge _ <br /> ❑Public/Commercial-Describe Use t <br /> w ship A4 w <br /> ❑State Owned 'Nearest Road <br /> .v fri LK br, <br /> III.Type of Permit: (Check only one box online A(numbering scheme for internal use). Complete me B if applicable) <br /> A. 1,2�New 2 [1 Replacement System 3 11 Replacement Replacement of 6 Addition to For County use <br /> S stem Tank Only Exisu 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 use) <br /> 44YIQon-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Co}lstructed 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.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 /> 3 0° �c 90097r 6- 7, <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab j Site Steel Fiber Plastic <br /> Gallons Gallons of Tants Concrete', Constructed Glass <br /> New Existing '! <br /> Tanks Tanks ! __ <br /> Septic or Holding Tank ab ,_ OG O <br /> Dosing Chamber Oo 1, `O V <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 /> Plumber's Address(Street,City,State,Zip Code) <br /> r <br /> O X S� ✓t B vJ LcT.$ � � �� <br /> County/De artment Use Only <br /> id Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issue I Issuing t S' nature( mps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination r-, <br /> IX. Conditions of Approval/Reasons for Disapproval n 1�r <br /> I <br /> AUG 2 2 S <br /> Attach complete plans(to the County only)for the system on Pape 1 s e <br /> ZONING <br /> SBD-6398 (R. 05/01) <br />