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Safety and Buildings Division County <br /> SO as 201 W. Washington Ave., P.O. Box 7162 U <br /> iscons�n Madison,WI 53707-7162 Sardtary Pelrmh Number(to be filled in by Co.) <br /> Department of Commerce (6D8)266-3151 551 zJ 1 <br /> Sanitary Permit Application State Plan I Number <br /> 1n accord with Comm 83.21,W is.Adm.Code,personal information you provide I <br /> may be used for secondary purposes Privacy law,sl5.04(INm) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Infortnation <br /> Prope wcer's Name L <br /> p/ Ct�� d fd6aH2O0P"0-I o3-don-asaoo <br /> Property Owner's Ma fling Address Property Location <br /> 867s a V fit- s11v <br /> %, NE 'A,Sectirm 4L) <br /> City,State Zip Code Phone Number <br /> C-rjetj ran ' n/ 16-6317 9 -Y0*-6 t5 or <br /> mic n > <br /> It. Type of Building(check all that apply) T�N; R E � <br /> tl or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use []City ❑village wnship of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A" 10 New system ❑ Replacement system ❑TratrnenrHold'mg Tank <br /> ligdxenrnt Only ❑ Odra modification to Existing System <br /> B. 11 Permit Renewal ❑ Permit Revision <br /> ❑ 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 a6 that ) - <br /> ❑ Non-Pressurised 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 Tm& ❑Pea[Filter ❑ Aerobic Treatment Unfit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filter ❑Leachmg Chamber ❑Drip Lim ❑Gmvd-fess Pipe ❑Other(explain) <br /> V. Dispersab7reatinent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Diapered Area Recluved(sf) Dispersal Area Proposed(sf) System Elevation <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 Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit ��WW <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,as®e resPousgAHtY far installation of the POWTS shown m the attached plans. <br /> PIK's Name(Prin i) 's Signa MP/MM Number ausirrss Phone Number <br /> &pro <br /> Plumber's Address(Street ,City,State,Zip ) <br /> MV JQrnf�lew W A1; <br /> VIII.Coun /Department Use Only <br /> ❑ Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stam <br /> Surcharge Fee) <br /> I0Owner Given Reason for Dermal <br /> IX.Conditions of Approval/Reasonsl�-"fns-Disapproval /% //// �� (e7 <br /> , ee- VaV* cC- Ta IUJ rtat� tank &Pff� bj 411114'$ 4fl-'4er40C. IJSry <br /> S 11 of Nw. AN � APR 2 0 2012 <br /> BUR ZE-rT ooU� <br /> Attach cumpkle piens(b the Consly anly)for the syslem a paper not les than 812 a 11 incbo ie sae <br /> SBD-6398 (R. 01103) <br />