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Safety and Buildings Division County <br /> ` ff 201 W.Washington Ave.,P.O.Box 7162 <br /> isconsin Madison,WI 53707—7162 Sani ary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 e35,Y <br /> Sanitary Permit Application State Plan 1.D.Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide 13.315,9,7 W, <br /> maybe used for secondary purposes Privacy Law,sl5.04(I)(m) Project Address(if different than mailing address) <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Nam, inG4�va Parcel Lot# —/5�_ BlockRg <br /> An JGvraev S� (ooPt ' OLID 9/7Sos6/O <br /> Property Owner's Mailing Address <br /> Property Location <br /> City,State Zip Code Phone Number _!4, —!/., Section of.O <br /> w 2b51l er -5-V (circle one) <br /> It.Type of Building(check all that apply) T 5!D N; R/6 E o& <br /> ❑ I or 2 Family Dwelling—Number of Bedrooms Subdivision Name CSM Number <br /> 1rPublic/Commemial—Describe Use A!?& <br /> ❑State Owned—Describe Use ❑City_ dlageZTownship of 04 k/.,,I <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System ,('Repl52rrement/Holding Tank Replacement Only ❑Other Modification to Existing SystemB• ❑Permit Renewal ❑Perme of ❑Permit Transfer to New List Previous Permit Number and Date IssuedBefore Expiration OwnerIV.T eofPOWTSS sem: C <br /> I�Non—Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> ConsWcted 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.DIS ersaIrrreatment Area Information: <br /> Design Flaw(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Si 9 7 7 vd ? Fe. 7 <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Plastic <br /> New Ezistina Concrete Constructed Glass <br /> Tanks Tanks <br /> Septic or Hiding Tank <br /> /dso /,iso / sic. <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 MPvi,IPRS Number <br /> / <br /> Business Phone Number/oy,S o 86 6 -4//s— <br /> Plumber'•s�Address t', et Ciry,State,Zip Code) <br /> VII Count /De art—­ <br /> Approved ❑Disapproved Sanitary Surcharge <br /> Perm : <br /> Fee(indudCCes Groundwater Date Issued Issuing a 19mu o Stamps) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Atmth eomplete Alam no the County only)for the system on paper not leas Mm 812 x 11 imher in slu <br /> SBD-6398 (R. 01/03) <br />