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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> NAIsconsin Madison,WI 53707-7162 San* t <br /> r(qqq be filled m by Co.) <br /> Department of Commerce (bog)266-3151 A72- <br /> Sanitary Permit Application <br /> State Plar <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 12 <br /> may be used for secondary purposes Privacy Law,sl5.04(1 xm) Project Address(if different than mailing address) <br /> LApplicationInformation—Please Print All Information tL MC 1, C <br /> ki <br /> Property Owner's Name �j- P I# Lo[# Block# <br /> Ne ' - a - K ` - Le -N -/8 �2 <br /> Property Owne's Mailing—Address Property LodAtion - <br /> ell <br /> City,State Zip Code Phone Number —% Section / 3 <br /> SS2 -Z (circle one) <br /> II.T of Building(check all that apply) T, (Z N; R r <br /> mSubdivision Name CSM Number <br /> s 5 <br /> Public/Commercial-Describe Use 4 rN�P m' t^ 2-I e 'k <br /> [I State Owned-Describe Use ❑CitX_ ilhgegowmhip of.SGb <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A- ❑New System1tI <br /> q Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of 13 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 apply) <br /> ❑Non-Pressurized In-Ground ❑Momd>24 in.of suitable soil ❑Motmd<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Comtiucted Wedand %Pressurized in-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber 0 Drip Line 13Gmvemess Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: 7 1011 r k 4 C <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed sf) System Elevation <br /> 750 _ 7 1071,25 ❑ 088'. S 10- 2 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New I Existing <br /> Tanks Tank <br /> Septic in Holding Tank ZO r.,/t r I m rr. <br /> Aortic Treatment Unit W Vlr'r <br /> Dosing Chamber 1 — <br /> VII.Responsibility Statement-I,the undersigned,assume r nsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber' arae(Print +/' Plumber's SiMP/MPRS Number Business Phone Number - <br /> w <br /> Plumber's Address(Street,City,State,Zip Code) <br /> � `7 f C4 s 1; r,f ki/,e�,z5 l< Lj-)r yg7s <br /> VIU.County/Department Uie Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin Signatu Stamps) <br /> Surcharge Fee) CC//•,� T <br /> ❑Owner Given Reason for Denial ✓(l J�-v�, OL <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not leu than 81/2 a 11 inches in size <br /> SBD-6398 (R. 01/03) <br />