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Safety and Buildings Division Coun <br /> 201 W. Washington Ave., P.O. Box 7162 u►^N e f`l` <br /> Nvh4consin Madison, WI 53707 -7162 Site Address <br /> Department of Commerce 13 63 Co. h'd E <br /> Sanitary Permit Application Sanitary Permit Numbeerr/ <br /> In accord with Comm 83.21,Wis.Adm. Code, personal information you provide " eat`l 945 45 <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Ca,#aS )WAi692/ o0 <br /> Property Owner's Name Parcel Number <br /> Grace hsc PI a��- �l� 0- oc400 <br /> Property Owner's Mailing Address Property Location /-Ov,t LOT c3i., t� <br /> 33 -73 7-exa ve k .4:S ,(& T 4f0 N, R i4 E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> 51'. Lau i a.-k MN. SS4J-6 LaT 3 05(n <br /> 11. Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑ Public/Commercial-Describe Use <br /> ,Township ,$GD'f'7` <br /> ❑State Owned Nearest Road /� /� <br /> IhGk eh 7-i e ! ce <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 ❑ New 2 19 Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I I Tank Only Existing System <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 21 El Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> -300 _ <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks '11 <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber',ct,,..-�•-- MP/MPRS Number Business Phone Number <br /> 22S$S I 715= $66- 4157 <br /> lumber's Address(Street,City,State,Zip Code) <br /> -1 <br /> 27 Ino 0 144 35 £B , _�4-053 <br /> VIII. County/De aliment Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date IssuedIssuin ge ignamr Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse 3 W CP <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not las than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05/01) <br />