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Safety and Buildings Division Count` as 201 W.Washington Ave.,P.O.Box 7162 �u rn <br /> iscons�n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co <br /> Department of Commerce (608)266-3151 `{65 V <br /> Sanitary Permit Application State Plan <br /> QI.D..�Number <br /> In accord with Comm 83,2 1,Wis.Adm.Code,personal information you provide /,( 9 63 03 <br /> may he used for secondary purposes Privacy Law,a]5.04(1 xm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name ' <br /> nn Parcel# Lo[# �7 Block#a' <br /> ao v,ctne !, -stro`n NO- /7S 30 /00 <br /> Propertt1y O6wner's Mailing Address /l�I Property Location <br /> 0� OOI� L ONS f-rNP Rd. <br /> City,State Zip Code Phone Number —Y., -- —%, Section�- <br /> W - 6-419. ttir Sy 893 7/s- 866- 8796 (circle <br /> H.Type of Building(check all that apply) T�j2 N; R ; E o <br /> 91 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use Vi (bu 0. e <br /> ❑State Owned-Describe Use ❑City_ Village®Township of OA/G/a n pr <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System y Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> IL ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T e of PO <br /> WTS System: Check all that a I <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 I'Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersaVl'reatment Area Information: <br /> Design Flow(g <br /> pd) <br /> Design Soil Applicat#�=IgpalllareaRquired(sf) Dispersal Area Proposed(sf) System Elevation <br /> Capacity in Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> ank <br /> - <br /> Unit <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 Business Phone Number <br /> /,�fGk 1710leln R4,4r,,,,0 /�/ Js-gs-1 7/S 8610-�frs� <br /> Plumber's Address(Street,City,Stare,Zip Code) <br /> 776 a /5't 3S 1.//cbs�r ws s`�PS� <br /> V II.Court /De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Late Issued [ssuiggq��g Agent Signaure(No Stamps) <br /> Surcharge Fee)�� co❑Owner Given Reason for Denial -�'O�«O <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans it.the County only)for the system an paper not Ips than 81/2 a 11 inehcs in sin <br /> SBD-6398 (R. 01/03) <br />