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Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 QLA.rtl L°f7' <br /> `Ainsconsin Madison, WI 53707 -7162 Site Address <br /> Department of Commerce _ _ <br /> Sanitary Permit Application Sa utary Permit Number <br /> In accord with Comm 83.2 1,Wis. Adm. Code, personal information you provide ❑ Check if Revision �s�02� <br /> may be used for seconds purposes Privacy Law s15.04(1)'m) _ <br /> I. Application Information-Please Print All Information ) State Plan I.D. Number Arl <br /> �02 GOG 0 <br /> Property Owner's Name Parcel Number <br /> 1'k1 ;1<e, oag- 9d 00 09a00 <br /> Property Owner's Mailing Address Property Location <br /> 6999 Obtine Ave k 4;S " O T qO N, R <br /> City,State Zip Code Phone Number Lot lumber Block N,Iumber <br /> Subdivision Name CSM Number <br /> rh ve v ,/L-ave <br /> II.Type of Building(check all that apply) ❑City tb o j n <br /> Y 1 or 2 Family Dwelling -Number of Bedrooms 3 ❑Village <br /> ❑ PuNic.'Commercial-Describe Use ,yTownship _5'40 7"_7"_ _ <br /> ❑ State Owned Nearest Road <br /> Co ka(. <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 Xi Replacement System 3 Replacement of 6 ElAddition to For County use <br /> System Tank OnlyExistin 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 /> 44A Non-Pressurized In-Ground 2111 Mound 4,❑ Sand Filter 50❑ Constructed Wedand <br /> 22❑ Pressurized In-Gruund 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.11nch) Elevation <br /> qSO 900 900 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plasm; <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks TaNts _ <br /> Septic or Holding Tank /JGO - /OQO <br /> Dosing Chamber /00 &00 <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 /> L{ t02D /r/S1 <br /> lumber's Address(Street,City,State, Zip Code) <br /> 27 7 (ao 14w 35 Assrm _54513 <br /> VIII. County/ eartment Use 0fily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A nt gnamre Stamps) <br /> Surcharge Fee) <br /> Owner Given Initial Adverse �JC/1 <br /> Determination �S tJ�VV l <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less than 8112 x 11 Inches in size <br /> SBD-6398 (R. 05/01) <br />