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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 0& N e 77` <br /> isconsin Madison,W1 53707-7162 Sanitary Permit Iumber be filled in by Co) <br /> De artmentic Commerce (608)266.3151 <br /> Sanitary Permit Application Sae Plan I D. umber { <br /> In accord with Comm 53.21,Wis.Adm.Code,personal information you provide (.1 <br /> may be used for secondary purposes Privacy Law,at 5.04(I)(m) Project Address if different than mailing address) -_':I)(�3 <br /> 1. Application Information-Please Print All Information Q <br /> lod07 Lace �� /?� <br /> Property Owner's Name <br /> Parcel# Lot# ( Block# <br /> L OnH/C L3rM/slr.rw -��d r-o/dam <br /> Property Owner's Mailing Address Property Locatio <br /> 410'7 Lti/ce d6 ��. <br /> City,State Zip Code Phone Number NA-Y, Section aS- <br /> s.gtrfJrt �- tvj- SYd30 <br /> II.T 7rS-6S6 705,3 T y/ N; R# /(GE Oro type of Building(check all that apply) E o� <br /> 01 or2Family Dwelling-Number ofBedrooms 3 Subdivision Nam CSM Number <br /> ❑Public/Commercial-Describe Use [LimV, I , IS- <br /> E]State Owned-Describe Use ❑City_❑villag Township of sr✓tJ.f <br /> III.Type of Permit: (Check only one box on line !11 line B if applicable) <br /> FkrNmf-Prmsuri,,dl1­:Gm'.nd <br /> ❑News stem <br /> Y Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Moditica ion to Existing System <br /> ❑Permit Renew ❑Permit Revision ❑Change of ❑Permit Transfer[o New List Previous Pe YNumber and Date Issued <br /> Before ExpiratioPlumber Owner <br /> e of POWTS ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable sail ❑At-Grade ❑Si gle Pass Sand Filter ❑ <br /> Constructed Wetland ❑Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recircif ating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pi <br /> V.Dis ersaVm <br /> freatment Area Inforation: Pe El Other(explain) <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed SO po (at) ystem Elevation <br /> 41 <br /> . � Gv3 6ve <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Sit Steel Fiber <br /> Gallons Gallons of Units Plastic <br /> New Existing Concrete Const ted Glass <br /> Tanks Tanks <br /> Septic or Holding Tank 3� 7SV lo 70 <br /> Aerobic Treatment Unit `S�� ✓ <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the Ittil bed plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRs Number Busi ess Phone Number <br /> dick /`�a /ter, s ��,/+��Plumber's <br /> Address(Sveel,City,State,Zip Code) <br /> ,,1 760 yw 3S Ld/P6s�`Pi ttiS s' 8s� <br /> Viol.Count /De artment Use Out <br /> ldApproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui Age ignat o Stamps) <br /> ❑ �/ rJ�Owner Given Reason for Denial Surcharge Fee) !(f ✓`0 �` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach romplele ponos(to the County only)for the system on paper not less than 81Q x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />