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Safety and Buildings Division County <br /> ` 201 W. Washington Ave., P.O. Box 7162 �c,e/-,so 8 <br /> isconsin Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266.3151 gg32-7 <br /> Sanitary Permit Application State Plan I.D. Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide )3 0 603 2- <br /> my be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# Lot# 57 Block#' <br /> ,tJ Q, eta - _goo <br /> Property Owner's Ma iling Address Property Location <br /> City,State <br /> Zip Code Phone Number u, tG Section Q <br /> P�(� �.r fi✓ tT-91 3 (circle one) <br /> IL Type of Building(check all that apply) T i N; RE or� <br /> Vl or 2 Family Dwelling-Number of Bedrooms 3She CSM Number <br /> ElPublic/Commercial-Describe Use t.% Ake I <br /> ❑State Owned-Describe Use ❑City_❑Village�&ownship of <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. y9 New System ❑ Replacement System <br /> ❑ Treatment/Holding lank Replacement Only 11 Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer in New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <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 g 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(sp Dispersal Area Proposed(sQ 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 Existing <br /> (. <br /> v^.{^,� Tanks Tanks <br /> Sip_r Holding Tank �B <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation or the POWTS shown on the attached plans. <br /> Plumber's Name(Prin t) I Plumber's Signa are MP/MPRS Number Business Phone Number <br /> G✓ / t!�/o/m / 1 3%y�2�6 <br /> Plumber's Address(Street ,City,State,Zip Code) <br /> VIII County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing nt nature saps) <br /> ❑ Surcharge Fee) /� (� p L� <br /> Owner Given Reason for Denial <br /> Ax"AA11 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> r <br /> Attach complete Pisan(to the County only)For the system on paper sat leu ehm Bin x Il inchrs in rine <br /> SBD-6398 (R. 01/03) <br />