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Safety and Buildings Division County _ <br /> 201 W. Washington Ave., P.O.Box 7162 �4,� _;� (,�Z ��) S <br /> V iseonsin Madison, WI 53707-7162 Site Address <br /> • <br /> Department of Commerce a1 l 11a.�S1,C(\\ Pe. - ) <br /> C Sanitary Permit Number <br /> Sanitary Permit Application �u o 0 3 e <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> may be used for secondary 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 /> 03 '.).-010"1 -) 73 94110- <br /> TO rY1 �Gr rE�` <br /> Property Owner's Mailing Address Property Location <br /> 71 ci M0,r5 • 1 PairKv9cty 6wuSi.0 '.4:salT 7 N,R9 E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> t'\ai\ IS f.,XI I \J.) t , 5 31 1 bog-)5i-,)4/1-0 Subdivision Name CSM Number <br /> IL Type of Building(check all that apply) ❑City <br /> it 1 or 2 Family Dwelling-Number of Bedrooms t,'5 ❑Village M <br /> ❑Public/Commercial-Describe Use ® f ,Township `Ct.tt S L'iv <br /> ❑State Owned Nearest Road <br /> INNars\-sa_tk Plc,-.)/ <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). omplete line B If applicable) <br /> A. Fo Countiuse\�•.(,, .,, <br /> 1 ❑ New 2� Replacement System 3 ❑ Replacement of 6 ❑ Addition w / L /S./-0 '-,�`` <br /> System Tank Only Existing System r <br /> Permit Number ccC � <br /> B. ❑ Check if Sanitary Permit Previously Issued / Fca e <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) L'e - `"i2 <br /> 4419 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter '� -50 :Consu ited-Wetland <br /> 22❑ Pressurized In-Ground 41❑ Holding Tank 48❑ Single Pass 51❑Drip.Line , 4 ,. <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.) (MinJlnch) Elevation <br /> 1-15 (7 i ( as )13�. 48 , y 95 .5 <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 Tanks f <br /> . o /ooC' /cop`20o C / Dec i,11. e..:_ y X <br /> Dosing Chamber G o o (,,c o / t I k <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 Biisinrec Phone Number <br /> Timothy J. Jelle Cred#227525 608-845-7466 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 501 Commerce Parkway, Verona, Wi. 53593 <br /> VIII.County/Department Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> "Approved ❑ Disapproved Surcharge Fee) (r <br /> ❑ Owner Given Initial Adverse y 2-/s oZ'���ja,�c illej4� <br /> Determination v` <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> --� Se eo•W T r 6f fi ir(4 m EI✓T , <4 -e/02 ae <br /> E (f?"r� is 1 <br /> �—� PGgMB6R M(�d7 Y�IFY ,!'/2E � CpnrD/7,oi�/ of x !EPr 4fC ?F JVEcErfqea-y, <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 05/01) <br />