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1 <br /> L <br /> Safety and Buildings Division County <br /> ��s�ons�n 201 W. Washington Ave., P.O.Box 7162 ��Oa- 0-2.2e <br /> ` Madison,WI 53707—7162 Site Address <br /> � <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permtit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide J <br /> may be used for secondary ❑ Check if Revision <br /> y ndary purposes Privacy Law,s15.04(1)(m) <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> C/i le �ieioe eft o/ be i/elv7vm ( o'2 f,�s.1 L LC �D&s)D 5R-d 8//- 3 If- i�o-G <br /> Property Owner's Mailing Address�/ / Property Location <br /> 0 0 30 /e/K /`� N€ 14 Se- I4:S 3V T I N,R // E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> �cSl.d// /e- r S Subdivision Name CSM Number <br /> 3 5 3 _-- <br /> .Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 cluing-Number of Bedrooms � � <br /> ala <br /> blic/Commercial Describe Use CIO//' 4den S e <br /> Fftownship J <br /> u^ '--ei-C4-t K i c Ste Otawn <br /> Neare Roa <br /> I t'erceu;lle ) <br /> III. T of Pe 't: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑Addition to For County use <br /> A. 1 <br /> System Tank Only _ Existing System <br /> B• )Check if Sanitary Permit Previously Issued Permit Number Date Issilsd. <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) i '(/.> • , <br /> 44Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50 Coned Wetiand`. ,i'/ <br /> 22❑ Pressurized In-Ground 41❑ Holding Tank 48❑ Single Pass 5 , 'p Line f 6, <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑cedes„ < \> <br /> V.Dispersal/Treatment Area Information: r`r` <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate 'System-Ele n Final G e <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Eleva" o <br /> a i /( 70 8 76 3, o V <br /> // 'N7` 3- /16, } <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks /� J <br /> Septic r Holding Tank /00 - /o DD e / re sr <br /> Dosing Chamber /D Cud ad 1 l� ' ' <br /> VII. Responsibility Statement- I,the and ..= -. assume res nsibility for installation of the POWTS shown on the attached plans. <br /> P r' Name(Print) �/ .ire MP/MPRS Number Business hone Number <br /> Plumber's Address(Street;City,Scat-, • - <br /> 7 3c I Caellt1 ('oi v * aye_ Gu-'; if 3.5 2zq <br /> VIII. County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signatu. o •'• ••, <br /> Surcharge Fee) ��l cJ <br /> ❑ Owner Given Initial Adverse / � � ./ <br /> Determination _7 •j-\a° fa"24-0 ,:h+see( <br /> IX. Condition of Approval/Reasons for Disapproval <br /> , - r`oo, 1 `( A-.I A`C u u,,)—`( 'ZJ%I 14 r '( ak_ f4.0-v-rArtL ' `�i. jiz-- fir <br /> =P31 ..u_A'7 -.4 C- `Cite -s�.5°`CE1vl <br /> Attach complete plans(to the C my only)(or the system cm paper not less than 8112 x 11 inches In size <br /> SBD-6398 (R. 05/01) _ <br />