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Saf w and Builth,,,,,DI,IsI'm <br /> 01 W-Washington.Ase P.O.Bo,rtti ✓N{ --' <br /> Madison,W[ 53 07 - 162 Sanaar P.mut Number(to be LI d i ^y Co i <br /> ��scon �� (608)266-3151 / 7S Q <br /> Department of Commerce 9 <br /> Sanitary Permit Application State Plan 1 D.Number LO <br /> C)In accord with Comm 83 21,W is.Adm.Code,personal information you prow ide _ __ <br /> may be used for secondary purposes Privacy Law,s15.040)(in) Project Address(ifdifferent than mai1ing:ddres9) <br /> I. Application Information-Please Print All Information •-� <br /> y <br /> Property Owner's Name Parcel# Lot# 4 Block# <br /> 4&0b T-diner ©lol. - 9350 - OS'retv <br /> Property Owner's Mailing Address Property Location <br /> 3 7,P40 h/at Irotoon GiN <br /> City,State Zip Code Phone Number —�� Section /.3 <br /> V>jI iAv r (A/,z' SZ/$3D .7jS J,$Yj- 79Sb (circle one) <br /> II.Type of Building(check all that apply) 11 i o(l? <br /> 5�1 or 2 Family Dwelling-Number of Bedrooms O\ Subdivision Name CSM Number <br /> 11Public/Commercial-Describe Use 1 <br /> V `" <br /> ❑State Owned-Describe Use ❑Ciry_0 V dIage 19Township of xA"KjOn <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. ❑ Treatment/Holdin Tank Replacement Only ❑ Other Modification to Existing 5 stem <br /> ❑ New System �Replacement System g p y g y <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of L]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 app l.._ <br /> Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter L <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Dnp Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 600 90 6 n..6 <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 7rO 74r49 <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 MPWPRS Number Business Phone Number <br /> R,e/c f/o ,E, •S /2 � �+l s �s/ 7is--g6G- 41-1•7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 ll .y web ,r, UIX- s-.f89.3 <br /> VIII County/Department Use Only <br /> Approved ❑ Disepprmved Sanitary Permit Fee l includes Groundwater Date Issued Issuii ignature tamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less tbao lill3 x 11 inches to sim <br /> SBD-6398 (R. 01/03) <br />