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Safety and Buildings Division County /i/ L <br /> 201 W.Washington Ave.,P.O.Box 7162 /7Uf nr f <br /> r <br /> liScOnS,n Madison,W1 53707-1162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 ,/72 2 b cI <br /> Department of Commerce "f' / <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Inform y� <br /> Lt DU/1 ✓I K iwC� 6 4-E <br /> Property Owner's Name Parcel# Lot# Block# <br /> Property Owner's Mailing Address 2'��-/ Property Location IC.J <br /> d -",4 / /., /., Section <br /> City,State Zip Code Phone Number <br /> J� N /t2 5-//J2� 7�1 2/D � �(csrclr W <br /> IL Type of Building(check all that apply) J O 'r ! "fir✓ T l_e" R�E or W <br /> I or 2 Family Dwelling-Number of Bedrooms ZSubee' CSM Number <br /> ❑Public/Commercial-Describe Use 1PIM46 O/Z 9775 0/ r40D <br /> El State Owned-Describe Use ❑City_❑Villa a Townshi g w Pof e-Jcic K e � <br /> 111.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. 1�New System ❑Replacement System ❑ TreatmentMolding Tank Replacement Only Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of ❑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 appi <br /> Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(so System Elevation <br /> 300 . �5- 6D0 6(!510 �.v <br /> Vl.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> -New-7 Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank / w <br /> Aerobic Treatment Unit i <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu er's Signature MPIMPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J,VII27140 w S (-Je6e-2xW- LJ,- <br /> VIII, <br /> Coun /Department Use Only <br /> Approved El Disapproved Sanitary Permit Fee(includes Groundwater I Date Issued Issuin A e t Sign i o Stamps) <br /> Surcharge Fee) Bj- C'f `'/ <br /> El Given Reason for Denial 4 �J(/� Z 1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/3 x 11 Inches in size <br /> SBD-6398 (R. 01/03) <br />