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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Qu?-off <br /> iseonsin Madison,W153707-7162 Sanita Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 35 <br /> Sanitary Permit Application State Plan ID Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide4 / �l <br /> maybe used for secondary purposes Privacy Law,s15.04(l)(m) Project Address(if dilferent than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# Lot# Block# <br /> od. lie"i� 0,% V 91010 Od Ado <br /> Property Own s Mailing Address Property Location <br /> ii �/0 3�rtf Ar.r <br /> City,State Zip Code Phone Number �• _'/, Section !7 <br /> 507-83_r- 776 circle one) <br /> Wea CC IMS T y0 N; R /iEorW <br /> I1.Type of wilding(check all that apply) <br /> Nr CS{ <br /> � ,� <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name v�� 2 Nurn r <br /> to <br /> t-F- <br /> ❑Public/Commercial-Describe Use c1srg V. <br /> C3 State Owned-Describe Use ❑City_❑Village kownship of OOK'anOQ <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' CY stem News <br /> System Cl Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal El Permit Revision ❑Change of C1 Permit Transfer to New <br /> 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 PrHoldingTank ❑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 ersaffreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> VL 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 A Oe0 o1000 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VI 1.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 /> Plumber's Address(Street,City,State,Zip Code) <br /> Z»60 H j 3s-' we6ste., W,-- S't9'4_�P <br /> VII oun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit In(includes Groundwater Date Issued Issuing ignatu tamps) <br /> Surcharge Fee) �r �0 S A <br /> ❑Owner Given Reason for Denial '�/ / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> kppAU*0 by Zoojjp* CosIlMlrW AT' 1775 y1/5'Qq P41,r, HtsnekAcr <br /> Attach complete plans(to the County only)for the system on paper not less than 812 all inches in size <br /> SBD-6398 (R. 01/03) <br />