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Safety and Buildings Division Ccm:t <br /> 201 W.Washington Ave.,P.O. Box 7162 <br /> isconsin Madison,WI 53707-7162 Sanitary Penn Number(to be filled in by Co.) <br /> Department of Commerce (0266-3151 <br /> Sanitary Permit Application State Plan//I.D. Number `U1 <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide a n L` �24)iecq <br /> may be used for secondary purposes Privacy Law,s15.04(1Hm) Project Address(if different than mailing address) <br /> I. Application Information-Plem Print All Information Q/� <br /> Ul(J� 9634 17amels 70 <br /> Proper Ow is N Parcel/ L�f Block#A l) 1 <br /> o7-oofr-2•�a-.17_21.6 05-001.0)8000 <br /> C � -e z <br /> Property Owner's Ma ding Address Property Location /` / I <br /> N• r %, ='A,,Section Z <br /> City,Stare Zip Code Phore Number <br /> err syB �s 6 -zaq � p (eircle > <br /> It.Type of Building(check all that apply) 2 T 1(L N; R �7 E q0 <br /> r.I or 2 Family Dwelling-Number of Bedrooms / Subdivision Name �j/f�,CSSMCN'umber <br /> ElPubPublic/Commercial /�6Q, <br /> Commercial-Describe Use v "r Z?erb <br /> ❑Scam Owned-Describe Use ❑City ❑Village ptbwnship of /u` <br /> III.Type of Permit: (Check only one box on fine A. Complete title B if applicable) <br /> A' ❑ New System ❑ Replacement system 19 TreaurmwHoldug' Tank <br /> Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision 13 Change of ❑Permit Tramfer in New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owren .1r,590 <br /> 7V -7— '83 <br /> IV.Type of POWTS System: (Check all that ) a <br /> ❑ Non-Pressurized Int-Ground ❑ Mound >24 in. of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade Single Pass Sand Filter <br /> ❑ Constructed Weiland ❑ Pressurized In-Ground ❑ Holding Talc ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Fater <br /> ❑ Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Lie ❑Gravel-cess Pipe ❑Otter(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application RaWgpdsf) DicperuI Arca Required(sl) Dispersal Area Proposed(sf) System Elevation <br /> ExISEIag (e`f8 N)� d CExfsfi5 Gln) <br /> VI.Tank InfoCapacity in Total Number Mamfactarcr Prefab Site Steel Fiber Plastic <br /> Gallon Gallons of Unfits Concrete Constructed Glass <br /> New Existing <br /> T�atrn�ks Tants <br /> "W <br /> Septic or Holding Tank /060 � <br /> Aerobic Treaunent Unit t�W W <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility fa'installation of the POWTS storm on the attached plans. <br /> P her's Name(Pnn t) 'b sign WARS Number Business Phone Number <br /> uk <br /> Plumber's Address(Street ,City,State "p Code) <br /> 72Z4 mfg lid VjG/ , <br /> � L.,)(* <br /> VIII.County/Department Use Only <br /> Approved El Disapproved Sanitary Permit Fee(includes Groundwater Date[awed ksuig Signamr Stamps) <br /> 11 Owner Given Reason for Denial ) 3�5 17144 Zoll <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach co splem plass(to the Conry only)for lbe systen on pryer not ka own 812 x 11 inches in arse <br /> SBD-6398 (R. 01/03) <br />