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Safety and Buildings Division County <br /> ` 201 W.Wasbingloo Ave.,P.O.Box 7162 <br /> iseonsin Madison, WI 53707-7162 Sanitary Permit Number(14 filled in by Co.) <br /> De artment of Commerce (608)266-3151 5 7 <br /> Sanitary Permit Application Sum /Plan I.D.NumM <br /> In accord with C nuu 83.21,Wis.Adm.Cnde,persurel mf s matio s you provide / 7 <br /> meY be usd for seanday Wrymm Privacy Isw,e1S.0a(Ixm) Projst AdNess(if difhrem then mailing address) <br /> I. Application Information-Neese Print All Information 3 <br /> property Owner's Name Parcel Y I.m M Block p <br /> /–A- (,)L'-NZ. <br /> Properly Owner's Me ding Address property loratinn �I t_, Gy L 3 <br /> C�ary^,Sae Z.P Cock Poore Numbs 4, u.Sation 7 <br /> stride > <br /> IL Type of Building(e k all that apply) T N; R�E o W <br /> '%J in 2 Family Dwelling-Number of Bedrooms --7' Subdivision Name CSM Number <br /> 0 Public/Commercial-Dexribe Use _ <br /> 0 Sum Owned-Describe Use OCit_"Yill�ge t�Toweship of 42 <br /> 9 fer <br /> III.Type of Permit. (Cheek only one box on line A. Complete line B if applicable) <br /> A' 0 New System -ARe i.nuem System 0 TreameWHOWing Tude Rrylacement Only ❑ Other Mdinwion in Existing System <br /> B. 0 permit Renewal 0 permit Revision 0 Clungc of 0 Permit Transfer m New List Previous Permit Number,and Dare Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> 0 Non-I'mesurmed In Ground 0 Mound > 24 in.of suitable sod 0 Mutual < 24 in,of satiable mil ❑ At G,We 0 Single Pass Sad Filter <br /> 0 C rustre ed Wedand 0 Pressurized In-Gtoud X Held.,Tank 0 Pea Fiber 1-1 Aerobk Treatment Unit 0 Rceirculaung Sad Filrer <br /> 0 Reeimudating Symhetic Media Filter 0 Leaching Clamber 0 Drip Lim 0 Gravel-leu Pipe 0 Otter(explain) <br /> V.DIS rsolV77atment Aree Information: <br /> Design Flow(gpd) Design Soil Application Rak(gpdsf, I Dispersal Area Required!(so Dispersal Arra Proposed B0 I System Elevaion <br /> AVW, <br /> apacity in Toad Number Mamfacmrer Prefab Sim Sweet Fiber Plastic <br /> Callose Gallons of Units Cunerew Comoucud Glees <br /> E..,,,,g <br /> Tale <br /> f� '— <br /> VR.Responsibility Statement- I,the uudersipad,assume responsibility for Installation of the POWTS shows on the atatlied plass. <br /> Plumbm'a Name(Prin Q�L Plumber's Signs m MPIMPRS Number Business Phone Number <br /> &JA'II– yrs/'/n) CJ_ �G = 69/ <br /> Plumber's Address(Stan .City,Sun.Zip Code) <br /> VIII.Count /De artment Use Only <br /> Rf Approved 0 Disapproved Sanitary Permit In(miudee Groundwater Date(S4aed Issu Sipa o Stamps) <br /> ❑ OwnQ Given Recon for Denial I Sanclearge Fee) <br /> IX.Conditions of Approval/Reasams for Disapproval <br /> Arrurh mmpele pease an the County seryl for the synes on paper me me ran all x 11 mass W tlu <br /> SBD-6398 (R. 01103) <br />