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No � t33e�y ooze Buildings Division County �L <br /> E p II A 201 W.Washington Ave.,P.O.Box 7162 uj Gt h r r <br /> • t �� " ` ,`� <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-31ST ! 0 ` E*/ . , <br /> —I <br /> Sanitary Permit APP lication State Plan LD Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(1)(m) Project Address(if different than mailing address) (C) <br /> 1. Application Information-Please Print All Information J. <br /> CZ. 3103 Li3g3 7Auoierbirel 0: c- <br /> Property Owner's Name Parcel# Lot# Block# <br /> [ teet>1- Sc 44 wbSch/tf.€r O /a.- 97Oo -o y - fop . <br /> Property Owner's Mailing Address <br /> Property Location - 33 . <br /> RQ OX cte6 y,, /,, Section /S <br /> City,State Zip Code Phone Number <br /> 0.3.6 et,/I (A-4.r 5—(74010 -7/s`-7rs•-3 8'7` /-CL <br /> t e) <br /> II.Type of Building(check all that apply) )) T 40 N; R�a E. n' <br /> jai or 2 Family Dwelling-Number of Bedrooms 02-- <br /> . <br /> am Subdivision Name Q�1 CSMlNumber+/ <br /> ❑Public/Commercial-Describe Use 7u rd er bi cc f- cU. I t U. V V <br /> ❑State Owned-Describe Use ❑City_❑Village, Township of Jae-kdaft <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. )fnNew System ❑Replacement System y p y ❑Treatment/Holding Tank Replacement Only II Other Modification to Existing System <br /> B. ❑Permit Renewal 0 Permit Revision ❑Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> 4 Non-Pressurized In-Ground 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade 0 Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground 0 Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter 0 Leaching Chamber ❑Drip Line 0 Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> - <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 . 5 r'eo coo 904. 6 <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 t 19:10 rao ( s,4y..a/ xr <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 ,�yy MP/MPRS Number Business Phone Number <br /> ALk- /10,4-,r S 4'-e 7s'oa Ai s`8-s`/ 7s76-6G- ,-,,,,s-2 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> el 776D ,y,....y 3.S- k/_djf,..i .dj ....”'gS ) <br /> VI.County/Department Use Only <br /> cApproved 0 Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issum gent Signature(No Stamps) <br /> Surcharge Fee) "�5�00 q-DY--D/ �� �)'�j, r <br /> ❑Owner Given Reason for Denial � `( to ' t",+�r) <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ke?Ibte. C -P(( 1)efm'i-e,#( 356/53 <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 />