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Safety and Buildings Division County pp <br /> 201 W.Washington Ave.,P.O.Box 7162 [Jus ✓1-e <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> 101isconsin (608)266-3151 <br /> Department of Commerce <br /> State Plan I.D.Number <br /> Sanitary Permit Applicatiton 9--)- <br /> in accord with Comm 53.21,Wis.Adm.Code,Personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information 290 <br /> Property Owner's Name Parcel# Lot# Block# <br /> G eo r ;A- moi'Yt�na ti <br /> Property Owner's Mailing Address n Property Location <br /> 3 0 d 9 f Al J`tie/ /T d e y., ,'/., Section 2._ <br /> City,Slate Lzip Code Phone Number <br /> �a 5u r 6 7gS9 G �(turtle OAC) <br /> ,' 'L✓s r = S <br /> �o T /I N. RE o <br /> II.Type of Building(check all that apply) Subdivision Name CSM Number <br /> ,K I or 2 Family Dwelling-Number of Bedrooms <br /> bn �, � <br /> 13Public/Commercial-Describe Use <br /> ❑City_❑village)Township of Jrw/JS <br /> El State Owned-Describe Use <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> JB. E1 <br /> New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to NewList Previous Permit Number and Date Issued <br /> ore Expiration Plumber Ownerof POWTS System- Check all that a 1 <br /> 11 Non-Pressurized ht-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑ At-Grade ❑Single Pass Sand Filter 11Constructed Wetland El Pressurized In-Ground ❑Holding Tank [I Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter C1 <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip lane ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dia ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate( t) Dispersal Area Required(sf) Dispersal Area Proposed(so System Elevation <br /> 300 S 600 6oD '736 93.E <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 g00 <br /> Aerobic Treatment Unit <br /> timing 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/MFRS Number' i Business Phone Number <br /> /t'ic k f/o ,�i.>•r I�-�sd�u� / a�t s-mss <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> J- 7760 i`/w y u/B 6 v/-e,r <br /> II.County/Department Use Onl <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issm Agent Signature(No Stamps) <br /> pproved ❑Disapproved Surcharge Fee) -��Qc) ))a(l � _} <br /> ❑Owner Given Reason for Denial _/ <br /> IX Conditions of Approval/Reasons for Disapproval <br /> L �I <br /> NOV 2 2004 <br /> Attach complete plain(to the County only)for the system on paper not lest than all2 x 11 luc 7pN1NG <br /> SBD-6398 (R. 01/03) L <br />