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Safety and Buildings Utvision c:oun7 f <br /> 201 W. Washington Ave.,P.O. Box 7162 `i/`�✓e— <br /> w in Madison,WI 53707-7162 Site Address <br /> iscons <br /> Department of Commerce s3`1 w00 (a n� 77 <br /> Sanitary Permit Application Sanitary Permit Number <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision '�z z z <br /> may be used for second purposes PrivacyLaw,sty. txm <br /> State Plan I.D.Number <br /> I. Application Information-Please Print All Inform '�G �s/ 10 9 69 O 17 <br /> Property Owner's Name1 Parcel Number <br /> 199A-r /,o .,J / Day �? 5 0 q 000 <br /> Property Owner's Mailing Address Property Location P c (!; <br /> O X -3 / 47 A 'A:S7 T3 �N.R�� <br /> City,State Zip Code Phone Number Loot Number Bleck Number <br /> Su69hiswrr142me CSM Numbe <br /> II.Type of Building(check all that apply) ❑City _ <br /> Y"r 2 Family Dwelling-Number of Bedrooms ❑Village _ <br /> ❑Public/Commercial-Describe Use VTownship La 1--D <br /> ❑State Owned Nearest Road <br /> III.Type of Permit: (Check only one box on liinppe��A(numbering scheme for.internal use). Complete line B if applicable) <br /> A. 1 ❑ New 2 ❑ Replacement System 3�txseplacermin of 6 ❑ Addition to For County use <br /> System Tank Oniv I Existing <br /> xistin S stem <br /> ,-,/ Permit Number Dtie Issued <br /> B. la[Check if Sanitary Permit Previously Issued 40(o co (p -/3 ' �3 <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-pressurized In-Grountd 215kMound 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/Treat ent Area Information: <br /> Design Flow(gpd) Dispersal Arca Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 00 GPI) -k-x p4t, Pte. Ao, 7 _5e e 00" 5e e /Lt <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sitel Fiber Ph.;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanlu Tanks <br /> Septic or italdia§-T** 1;1�0 <br /> Dosing Chamber Sav �ev <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached phos. <br /> Plumber's Name(Prui% Plumber's Signature MP/MPRS Number Business Phon:Number <br /> Plumber's Address(Street,City,Sure,Zip Code) <br /> VII1. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A Si nature( n ps) <br /> Surcharge Fee) �r <br /> ❑ Owner Given Initial Adverse by Com\ l f Qvf_ <br /> Determination <br /> LX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 It 11 inches in size <br /> SBD-6398 (R. 05/01) <br />