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Safety and Buildings Division County <br /> \Vlfisconsin <br /> 201 W.Washington Ave.,P.O.Box'162 BGt✓heA`-Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 (I <br /> - Department of Commerce 7 Z j <br /> Sanitary Permit Application State Plan 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(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information 01 8008 <br /> Property Owner's Name , Parcel# Lot# Block# v,J <br /> h r i 03 6- BIOS_ O/'S a <br /> Property Owner's Mailing Addfcss Property Location <br /> 7�r/.3 Fron�it!r �i�. I/, '/., Section 30 <br /> City,State Zip Code Phone Number - <br /> Cloa rl s n /»N s s3/7 4tJt- sr6 9Jr-S3/ (cuele W) <br /> T 4�O N; RAZE <br /> II.Type of Building(check all that apply) <br /> Iff <br /> 5r1 or 2 Family Dwelling-Number of Bedrooms T Subdivision Nat(�9e CSM Number <br /> ❑Public/Commercial-Describe Use �Cf 1 ��{( <br /> El State Owned-Describe Use ❑City_❑Villagc Township of it fpit <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System KrReplaceincnt 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 Dale 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 ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sl) System Elevation <br /> el v00 �S7 <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 Unit <br /> Dosing Chamber <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 /> Plumber's Address(Street,City,State,Zip Code) <br /> J 7760 /4 �il.sr lk/eGsAe wll_Y1rA6:"93 <br /> VIII.Coun /De artment Use Only <br /> ❑ Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing t gnatu o Stamps) <br /> Surcharge Fee) 4 <br /> X <br /> �/, r <br /> ❑Owner Given Reason for Denial �jV '/N7 2S� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Soft i 5dr- 6tUa10af4lu of s- /9- 05 , 8y 7, t5e. <br /> SOtLs �/6i21FC4tlotu of MAY l9, .2o05, t on;FrRa60 TN?? 7Hca1E 15; 1)4I_ANrr*9 <br /> 5�tLs vI� TN f S Si7E. <br /> Attach complete plans(to the County only)for the system on paper not less than 812 x 11 inches in sin <br /> SBD-6398 (R. 01/03) <br />