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Safety and Buildings Division County <br /> Visconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 UrNMadison,WI 53707-7162 Sanitary Permit Number(to be filed in by Co.) <br /> De artment of Commerce (608)266-3151 C_3� <br /> Sanitary Permit Application State PI_anI.I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(l Hm) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information �k wa � <br /> Property Owner's Name ^� Parcel H Lo[ Block k <br /> Jc,Gi/V /i 1 f` 3 Z - !- <br /> Property Owner's Mailing Address Property Location <br /> W 2,-203 1&rktv /U /8 <br /> o <br /> City,State Zip Code Phone Number — - --�• Section <br /> elN Sti7,a 686"- "0 ircle e> <br /> ( T // N: R�'�E o W <br /> 11.Type of Building(check all that apply) q <br /> 61 or2Family Dwelling-Number ofBedrooms S <br /> ubd <br /> ivisionName CSM Nmber <br /> ❑Public/Commercial-Describe Use <br /> El State Owned-Describe Use ❑City_❑Village1QTownship of! DCdi! -2 <br /> III.Type of Permit: (Check-only boz on line A. Complete line B if applicable) <br /> A <br /> ew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe El Other(explain) <br /> V.Dis ersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(at) SystemElevat. <br /> 300 . 7 kae H28 47 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Umit <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu er's Name term Plum s$ignatu MPRNPRS Number Business Phone Number <br /> e, OI �� dSrP 715) —t0 <br /> Plumber'sAddress(Street,City,Slate,Zip C/ <br /> Ci �LraZ #ir�^j <br /> I.Count /De artment Use Onl <br /> proved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dale Issued Isswnggg'''���...gent Signature(No Stamps) <br /> Sorcharge Fee) -['335 UD <br /> El Owner Given Reason for Denial -J.Y lJ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County on for the system oa paper not less than 81/S x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />