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Safety and Buildings Division CountyAll <br /> NVisconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4-35,3,2 +f 3Q2Z <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information n � L O n j lak v <br /> Property Owner's Name C Parcel k 1 e6 t Block-0- <br /> Steve VurknshAW OSS- 4iloq_03 80rS" <br /> Property Owner's Mailing Address Property Location <br /> 60;, N H154 57` <br /> City,State Zip Code Phone Number $ 1/., 'sGf�y, Section <br /> L+Q�GE Gif mN. SSOy� GSl-3g6-- (circleo ) <br /> 'i9yg <br /> II.Type of Building(check all that apply) T �� N; R�E or <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number�SI l l �/ <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City ❑Village ZTownship of sod ll�� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ;R New System El Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit RevisionChange of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ❑ <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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sI) System Elevation <br /> 3 e 1 .S 606 6M 194Jaa.Yr 93.7C.,OA <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 7rO 75-0 J S kaw 1 C <br /> Aerobic Treatment Unit <br /> Dosing Chamber S40t4 sib 45A J%e <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 /> Rk-rc ff �; �25gS lis- 80 -qis--7 <br /> Plumber's Address(street,City,State,Zip Code) <br /> J•7760 f/w y 3 5- Wt6_4)4e - 14/ — sriS9 <br /> VI .Coun /De artment Use Only <br /> Sanitary Permit Fee ncludes Groundwater Date Issued Issuin t Sign r o Stamps <br /> Approved 11 Disapproved Surcharge Fee) "1�r/'� a � � �3 p ) <br /> 11 Owner Given Reason for Denial O( V <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> C,� I�rl�l5l <br /> LJ <br /> AU6 <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches is size Nr.` <br /> I r ZONING <br /> SBD-6398 (R. 01/03) <br />