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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Litt v l e Ir <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> De artment of Commerce (608)266-3161 z <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,sI 5.04(1)(m) Project Address(if different than mailing address) <br /> Lferry R6- <br /> Application Information-Please Print All Information <br /> Property Owner's Name J Parcel 4 Lot q x Block 4 <br /> JosA Petal GertHlw tofiq <br /> Property Owner's Mailing Address Property Location <br /> lSS•D S3 Sao /��• <br /> $E � $w •G, Section <br /> City,State Zip Code Phone Number <br /> (rra.nl�s6ra. 1 ,y Syayp 71r-463-39/d (circle_) <br /> T 39 N; RAE o <br /> 11.Type of Building(check all that apply) <br /> 91 or2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> V <br /> ❑Public/Commercial-Describe Use V_J4 /SD <br /> ❑State Owned-Describe Use ❑City ❑village Township of W. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' Pr New System y El Replacement System ❑Treatment/Holding Tank Replacement Only El 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 apply) <br /> YNon-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 inof 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 Raw(gpdsf) I Dispersal Area Required(sl) Dispersal Area Proposed(sf) System Elevation <br /> 4/5-D . 7 (o 1f 3 a0 el 9 94 e <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /0e0 <br /> /off <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VI 1.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> R;e-1- �o o(,t�esi lis 866 - 4elj-> <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77(19 /ya 3S W-4- <br /> Sf893 <br /> ,VIIII.Count /De artment Use Only <br /> 1� Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing t Signatur o Stamps) <br /> 570 ye <br /> El Owner <br /> Fee)Owner Given Reason for Denial � 25� Mfe!zsr•' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the gaiaa on paper not less than al/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />