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Safety and Buildings Division County <br /> Visconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 (3u.rn Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce <br /> (608)266-3151 4c 3 3 <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,sI5.04(I)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel 4 Lot N as Black N 00 <br /> err y 12A-1-J OJA 907.5"0 "S 610 <br /> Property Owner's Mailing Address Property Location <br /> oL7S-39 Je0e,e-f /�cQ• <br /> City,State Zip Code Phone Number —!4• —Y.• Section <br /> WeA,41-e.- W_r 5 '-I,? 7�f. 866-4/3v T_N; R /40 aEorrcleo�) <br /> II.Type of Building(check all that apply) <br /> 01 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM NumberT <br /> 11 Public/Commercial-Describe Use t}-CXM ngy- <br /> El State Owned-Describe Use ❑City_❑Village ffTownship of Ja olc.e s n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. News stem <br /> y y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B. ❑Permit Renewal ❑ Permit Revision 11hange of ❑Permit Transfer to New List Previous Permit Number and Date issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stem: Check all that apply) <br /> jl�Non 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.Di s ersaVl'reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(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 Existing <br /> Tanks Tanks <br /> Septic or Holding Tank gee 8040 s�� r✓ u <br /> Aerobic Treatment Unit �J <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's SignatureMP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 N, 3S f_/e6tfr/ <br /> ,V�,,IIII�I.County/Department Use Ord <br /> lYApproved El Disapproved SanitaryPermit Fee(includes Groundwater Date Issued Issuin ge ignatur o <br /> �U Sumps) <br /> Surcharge Fee) ` � �� /`,I <br /> 10 Owner Given Reason for Denial V <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not las than 812 x 11 inchn in siu <br /> SBD-6398 (R. 01/03) <br />