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Safety and Buildings Division County <br /> Mis <br /> 201 W.Washington Ave.,P.O.Box 7162consin Madison,WI 53707-7162 Sanitary PermitNumber(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I D.Mumber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl So I)(m) Project Address(if different than mailing address) f� <br /> 1. Application Information-Please Print All Information I ' 1 <br /> r Olaf 3-r v <br /> Property Ow <br /> /ne <br /> 'r's Name T Parcel# Lot# Block# <br /> Property Owner's Mailing Address Property Location <br /> 4Q <br /> City,Slate Zip Code Phone Number —39 N; R !b ys NW yg Section <br /> Utdn�tS ff f iY/N SSl� 7 yS!- 63"3-9e$J (cirE cor le <br /> T ) <br /> It.Type of Building(check all that apply) <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> El State Owned-Describe Use ❑City_❑Village 8Township of W&CA10A <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. .'New System y 11 Replacement System ❑Treatment/Holding Tank Replacement Only El 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 /> 4 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.Dis ersal/I'reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(s 1 Dispersal Area Proposed(sSystem Elevation <br /> 300 , 7 `��9 �r3J9s• 4 <br /> ;A..bic <br /> ank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Exisdng <br /> Tanks Tanks <br /> r Holding Tank -,7 ?S0 <br /> Treatment Unit <br /> Chamber 5 oa S-o0 <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 MPIMPRS Number Business Phone Number <br /> Reck II din s //��Ia„��' �� 5 8S/ ?/r-866 ^G/S'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ol <br /> 7760 /%w 3 Gr/e65�t✓ Gt/r S48 g <br /> VI .Coun /De artment Use Ont <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ent ignatur o Stamps) <br /> Surcharge Fee) <br /> El Owner Given Reason for Denial c7 p( ZCJ r <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not Jere than sit x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />