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Safety and Buildings Division Lounry --+�- <br /> 201 W. Washington Ave., P.O. Box 7162 QurA <br /> Iseonsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce '704lF7 Rocrhbew 4, <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide C1 Check if Revision ��OD� <br /> may be used for second Purposes PrivacyLaw,s15 i)(m ec <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> Bob ,STeuew-C 0,,�0 - 93Pp D/-3D0 <br /> Pmperry Owner's Mailing Address Property Location <br /> 37oos. wes r;.r Ao. *770 u $A:s /6 T �iON. R/G <br /> City,State Zip Cade Phone Number Lot Number Bieck Number <br /> //�m <br /> � Subdivision Name 1—CSM Numbe <br /> D <br /> Si0L F0. /J S. . S'71e ic, R[ i <br /> II.Type of Building(check all that apply) ❑City <br /> ,ff I or 2 Family Dwelling-Number of Bedrooms tk ❑Village _ <br /> ❑Public/Commercial-Describe Use tftbwnship 6,44/i H oQ — <br /> ❑State Owned Nearest Road <br /> 2G/N�m✓ Ln <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicabl(.) <br /> A. IR New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Talc On) ExistingSystem <br /> B- ❑ Check if Sanitary Permit Previously Issued Pem,Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44A Non-Pressurized In-Grouod 210 Mound 47❑ Sand Filter 50❑ Constructed Welland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑ Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Rccirculaing 30❑Other <br /> V. Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Sod Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rare(GaIs./Days/Sq.FIJ (Min.linch) 4 9S 9 Elevation <br /> q CF.o <br /> 9G O <br /> VI. Tank Inco Capacity in Tout Number Manufacturer Prefab Site Seel Fiber PI; aie <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> T6anks Tudts <br /> Septic or Holding Fa <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for institution of the POWTS shown on the attached pl:.ay. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> 1?1ck f/a Fiat /2 �J s85Y lis- 866-y/s`7 <br /> Plumber's Address(Street,City,Sure,Zip Code) <br /> ,� 7760 // 3 <br /> V'II/I. Count IDe artment Use Only <br /> la Approved 11 Disapproved Sanitary Permit Fee(includes Groundwater Dare Issued Issuin g .Sigmtur uc ps) <br /> Surcharge Fee) AYS((94 o(- <br /> ❑ Owner Given Initial Adverse aL CC^^ <br /> Determination <br /> IX. Conditions or Approvalflteasous for Disapproval <br /> Attach complete plant(to the Couuty Daly)for the system an paper not lest than 6112 s 11 inches torise <br /> SBD-6398 (R. 05/01) <br />