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Safety and Buildings Division County /� <br /> t�h <br /> N*sconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 1S Le i f <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 43S 2 G 2 <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,s 15.04(1)(m) Project Address(if different thanmailingaddress) <br /> I. Application Information—Please Print All Information 3 7/0 J4 4t dot <br /> Property Owner's Name Parcel# Lot#O 60O Block# <br /> Oep AX.cs otJ, -YJ 36- <br /> Property Owner's Mailing Address Property Location 0Vt,�_- c,T <br /> 7464 dir,42i-d CnN .,%, tZ� %, Section JL6 <br /> City,State Zip Code Phone Number <br /> M^10/se GYOVC M N. s3!/ 743-`otO7&k3vele one) <br /> II.Type of Building(check all that apply) T �0 N; R / E or® <br /> IN 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> L3Public/Commercial-Describe Use UT V 1 Ol a <br /> ❑State Owned-Describe Use ❑City_❑Village AlTownship of tf4 e/c S d h <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y B.Replacement System 0 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 d 1 <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(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(so System Elevation <br /> .?0( 1 . S*7 y�. 7 S/O 94.7 - 7S 9S" / <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 $0O <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,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 /> Rloic f!o kin s �J 5"Pr1 7/s- g66- 5�is-� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1-7760 Nt,. 3S- <br /> VIII.County/Department Use.Onl <br /> Approved ❑.Disapproved ' Sanitary Permit Fee line odes Groundwater Date Issued Issui A t Sign re o Stamps) <br /> Surcharge Fee) �7'� <br /> ElOwner Given Reason for Denial �t/l/ � 63 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> FX157laXr 57AMD Fbm) 4)6L.(— aha(( be YlFw("eCOL <br /> The wsT4cG.*-ri 1 of rhtC svrL- Atsoa-e-1o+N Gens. <br /> << qUc <br /> ��RNF 2s <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 z 11 inches in size O C <br /> SBD-6398 (R. 01/03) <br />