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Safety and Buildings Division County <br /> AANN*isconsin 201 W.Washington Ave.,P.O.Box 7162 Y-Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 - <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,aI5.04(1)(m) Project Address(if different than mailing address) S) <br /> I. Application Information-Please Print All Information 31360 <br /> NwY 3 S` y <br /> (JI)4tg64 <br /> Property Owner's Name Parcel# Lot# 3 Block# <br /> ait M t.V- Aw 03,,_ r3)OLd/_7od <br /> Property Owner's Mailing Address Property Location <br /> 7d BG/f 3•�J� '/s, NE Y., Section 01 <br /> City,State Zip Code Phone Number <br /> DArl�ur W� .5-4 �30 7/s--dS(y -- '777° �� (Circle�e) <br /> T N; R /b E o <br /> II.Type of Building(check all that apply) <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number] <br /> ❑Public/Commercial-Describe Use L5 r 3 J. <br /> ❑State Owned-Describe Use ❑CiTy ❑Village J&Township of 5wJ-%.1 W <br /> HI.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A' 9 New System y El Replacement System ❑Treatment/Holding Tank 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 /> 9 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 ❑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(sf) Dispersal Area Proposed(sf) System Elevation <br /> . 7 0`1 l4 d,/Ir gy. w <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 I Tanks <br /> Septic or Holding Tank m04 /00 D /ffoiw s SGd <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-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 /> KtejG �7& Aio f I A1.4 i Ol'Ises / *w:r__ '(iG_ q/.S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 01 '776 O lbw 3S W-C- C?eeV P9 3 <br /> II.Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin Agent Signature(No Stamps) <br /> Surcharge Fee) a/-"' !O I <br /> 11 Owner Given Reason for Denial UU <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> LL711� NV <br /> OCT t 3 2003 <br /> Attach complete plans(to the County only) NO srnl <br /> ys[garsgpanet JlQt less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />