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Safety and Buildings Division County <br /> N*isconsin 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,WI 53707—7162 Sanita, C <br /> i}i PI�1t Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 '�t� ?/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 /> maybe used for secondary purposes Privacy Law,sI S.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information a 2-$q 26 <br /> Property Owner's Name Parcel# Lot# Block# <br /> D R 0171675(PIC) -5 <br /> Property Ownef s Mailing Address Property Location <br /> -3s ci 1 q /-Tn '/. <br /> City,State �- Zip Code Phone <br /> �/ Phone Number %., , Section <br /> ire <br /> NPL. o 55 -1 1/1 TN; R ( EorWe) <br /> Il.Type of Building(check all that apply) <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms <br /> 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use Aumooti Iv.-T-0 V.V- <br /> ❑State Owned-Describe Use ❑City_❑VillageRqownship of-T)Y_1C.50M <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System y ❑ Replacement System Treatment/I .i'ank 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 /> IV.Type of POWTS System: Check all that apply) <br /> *rNon-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 ❑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.Dia ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Mea Proposed(st) 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 <br /> Aerobic Treatment Unit �V <br /> Dosing Chamber <br /> VII.Responsibility Statemeut-I,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 /> 1cNr�nn {}oPKln15 t✓l d r- 2zS-SS) <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,VIIIII.Coon /De artment Use nl <br /> w Approved El Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuinen ignatu tamps) <br /> ❑ <br /> Surcharge Fee) �oO�p ,/ <br /> Owner Given Reason for Denial M <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches In size <br /> SBD-6398 (R. 01/03) <br />