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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 1 t 1-N T/ f <br /> r <br /> \41.4consin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 4-99,5Z2- <br /> State <br /> Sanitary Permit Application State Plan I.D.Number / 11 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide IN <br /> may be used for secondary purposes Privacy Law,915.04(i)(m) Project Address(if different than mailing address) ( I'} <br /> I. Application Information-Please Print All Information <br /> Property 01's Name _ rcel# Lot# Block# <br /> "% .o a a.. .�Al/ ry <br /> Property Owner's Mailing Addresspl-&Crp <br /> Propert9 Location <br /> City,state Zip/Cad�e�� Pryhone Number <br /> �., , Section <br /> a.W L .0 V W ;/d�7 /�i r-7 Y6- 314" T c/O N, R�c' °W°k <br /> II.Type of Building(check all that apply) <br /> -9 1 or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name CSM Number <br /> El Public/Commereial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑VillagegTohipZ of <br /> III.Type of Permit: (Check only one hoz on line A. Complete line B if applinble) <br /> `t' ❑New System Replacement System ❑Treatment/Holding 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 /> W.Type of POWTS System: Check all that apply) <br /> XNon-PressurizedIn-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.Din ersan'eatment Arca Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required s Dis <br /> B ( f) pMal gree Proposed(sf) Syst Elevation Q <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New E�g <br /> Tanks Tanks <br /> Septic Idivg Tank � <br /> Aerobic Trnstment Unit As e\ XZ61 <br /> Dosing Chamber <br /> VII.Resoonsibtlity Statement- 1,the undersigned,as a mannnsibluty for Insmllation of the POWTS shown on the athicbed plans. <br /> Plumber's Namt�e(Print) Plumber-s 'gram /MPRs Number Business Phone Number <br /> Rmt <br /> Plumber' Address(Street,City,State,Zip Code) <br /> eb cle til <br /> VIII. <br /> CounlyiDepairtment Use Onl <br /> Approved I ❑Disapproved Sanitary Permit I"(includes Groundwater Date Issued Issuin ent Si (No Stamps) <br /> ❑ <br /> Owner Given Reason for Denial Surcharge Fee) J J <br /> IX.Conditions of Approval/Reasoos for Disapproval <br /> Atfaeh eompkte plain(to the Canvty ady)for the system on paper not Ins own gin s II Inches In alu <br /> SBD-6398 (R. 01/03) <br />