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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 A3 NA, <br /> Visconsin Madison,WI 53707-7162 SanitaryPermit Number(to be filled in h� Co ) <br /> of Commerce (608)266-3151 4 3 g 30D <br /> __ De artment _ <br /> Sanitary Permit Application State Plan I.D.Num{berr <br /> In aa:ord with Comm 83.2 1,W is.Adm Code,personal information you provide ®b✓ej <br /> may be used for secondary purposes Privacy Law,a15.04(lxm) <br /> L Application Information—Please Print All Information <br /> •Z13Z-o 700 <br /> Propern'Owner's Name Parcel a Lot a Block 4 <br /> c.Enn I–SEE <br /> Property Owner's Mailing Address Property Location <br /> 8�c7 2"94 <br /> t/a /)K)'/_.ESoec <br /> tion 3z- <br /> City, <br /> Z <br /> Chy,StatsZip Codno Numb (circle� <br /> —,CHE — L *,16 I� 6VJ071 — -7T3Q N; Ri <br /> Subdivision NameCSh�P:umbcr <br /> ❑City_❑Village 1'ownslupof_(_ <br /> 111 Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑ TreatmenUHolding Tank Replacement Only ❑ Other Modification to Existing System <br /> --—T— <br /> UJ Permit Renewal ❑ Pemtit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Datc Issued <br /> before Expiration Plumber Owner <br /> IV. Type of POWTS System: (Check all that apply) <br /> lNon-Pressunzed Ln-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ AI-Grade ❑ Single Pass Sand Filter ❑ Coactructed <br /> U'etland i Pressunzed In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ Recirculating Synthetic.Media <br /> Filter ❑Leaching Chamber ❑Dnp Line9—Gravel-less Pipe ❑Other(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> .300 . 7 3z f,LSo 93.o ' <br /> �- <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber , Plastic <br /> Gallons Gallons of Units Concrete Constructed I Glass <br /> New Existing <br /> Tanks Tanks <br /> sear«u`a ap;. / o3Ki3cc� 5C <br /> 00 0 <br /> Aerobic Treatment lirm <br /> VII. Responsibility Statement- 1,the 4rsignedaVurne reo ibillty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pent lu s ture MP/MP umber Business Phone Number <br /> M&K SEs✓i 2 S LAoAVATIO N <br /> � �cle79 <br /> Piur���� W1' Code) — <br /> _ Ise County cpartment se Only <br /> r Salutary Pemut Fee((includes Groundwater Date Issued Issuin I Signa e(No Stamps) <br /> .approeed ❑ Disapproved Surcharge Fee) ��+�,/'�'� <br /> ❑ Owner Craven Reason for Denial IVJIVI �/l./ V,� d b3' <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> te,vilJ <br /> BGRIv�,�. <br /> Attach complete plans(to the County only)for the system an paper not less than 61/2%11 Inchu In slat s I `OU <br /> ZONING Nn' <br />