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Safety and Buildings Division County �[ <br /> N 201 W,Washington Ave.,P.O.Box 7162 5 4e r/.f eT <br /> 14sconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department Of Commerce (608)266-3151 4 9 8 38(, <br /> Sanitary Permit Application Sae Plan I.D.Number , <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 3.2 52 57 �J�J <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print AB Information <br /> Property Owner's Name ` <br /> Per"San 0 <br /> ] Lot# Block <br /> /' # <br /> Property Owner's Mailing Address LL / <br /> /C�iry,State.(f..r�,r S 'i Y sT G ZCode Property L,ocation <br /> �/ Phone Nw�bw � <br /> S <br /> Section <br /> SZU <br /> 5E <br /> II.Type of Bulldin (check all that apply) 3L TN; RteE orW <br /> 1(1 or 2 Family Dwelling-Number of Bedrooms 7 Subdivision None CSM Number <br /> 11V.Public/Commercial-Describe Use e /37 <br /> El State Owned-Describe Use ❑City_❑VillagejgTownshipof WOD <br /> E• r <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System / <br /> y �Replacement System ❑TreatmcnVHolding Tank Replacement Only '❑Other Modification to Existing System <br /> B. El Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to Newt`• Gat Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner p <br /> IV.Type of POWTS S stem: Check all that apply) <br /> ❑Non-Pressurized In-Ground nMound>24 in.of suitable soil ❑Mound<24 in.of suitab]esoil ;❑At-Grade ❑ Single Pass Send Filter* ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Pont Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Dri fine ❑Gravel-less Pipe: ❑Other(explain) <br /> V.Dia eraanreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gli Dispersal Area Required(at) .Dispersal Area Proposed(at) System Elevation <br /> O / (moo U /D/•� <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete ConsWcted Glass <br /> New Existing <br /> Tech Tanks <br /> S<tic rHolding Tack ✓' 7-600 <br /> Aerobic Trannem Udt r� <br /> Dosing Cha r <br /> VII.Responsibility Statement-1,the denlgaed,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P tuber's Sign MP/MPRS Number Business Phone Number <br /> � <S _ P r Lc� zz s z z 7i s 6�6 �bv� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Count /De artment Use Oni <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not ku thin 81R a I1 Inches In nee <br /> SBD-6398 (R. 01/03) <br />