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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> NVisconsin Madison, —7162 �' 56 q/3errnit (to be filled in by Co.) <br /> Department of Commerce (608))266-3156-315 1 <br /> Sanitary Permit Application State Plan I.D.Number <br /> V <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide / pt <br /> may be used for secondary purposes Privacy Law,sl 5.04(l xm) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Inforrmtiom <br /> -SAM11✓ LAMS <br /> Property Owner's Name Parcel# Lot# Block# <br /> CK A. +1 UPP-V--� c 12-4zz�-Ora -ESOa I.oT <br /> Property Owner's Mailing Address Property Location <br /> W (�"m (90'4 AVE- _ <br /> City,State Zip Code Phone Number %., Y.., Section <br /> jz <br /> \UQZ VALLS VT_ 1bZZ (]15�IZ10-1�� () �eeE <br /> 11.Type of Building(check all that apply) T N; R_E W <br /> *or2Family Dwelling-Number ofBedmoms ?� SubdivisionName <br /> �e CSM Number <br /> ❑Public/Commereial-Describe Use W V OL �(7 VU. <br /> ❑State Owned-Describe Use ❑City ❑Village*ownshipof_ 5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, XNcw System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. 11 Permit Renewal ❑Permit Revision ❑Change of 11 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> yyy(lrrr,,Vrrr.T of POWTS S Check all that a <br /> µ Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mould<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Weiland ❑Pressurized in-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip I= ❑Gravel-less Pipe ❑Oil=(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal 300 Area (so Arm Proposed ArProposed(so System Elevation 1). 4 q 4 qo I: 45.D Z:gt4.D <br /> V1.Tank Info Capmity 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 Hbidmg Tank b O 0 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWYS shown on the attached plans. <br /> Plumber's Name(Print) PI s Simi MP/MPRS Number Business Phone Number <br /> DA ELL i4 n/V4�/�� f 2_7_tbj7 5 (1r5)M <br /> Plumber's Address(Street,City,State,Zip Code) <br /> lJbtigD 5TH. b 8��-O>=►��tl�Tc, WL 51+00-5 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin g i (No Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial I P <br /> IX.Conditions of Approval/Reasous for Disapproval <br /> Attach complete plain(to the Comity only)for the system on paper not less Man SY2 z 11 inclw in size <br /> SBD-6398(R.01/03) <br />