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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 to /I ti C <br /> %sconsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce (608)266-3151 40a5 rl)9 <br /> State PIanVLD.Number <br /> Sanitary Permit Application �R�v 7�Z <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1 xm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> ao8y3 Oz.. <br /> Property Owner's Name Parcel# Lot# L Block# <br /> bCLJ'J E 03`/-/SZ/`08- t7pp <br /> Property Owner's Mailing Address Property Location Pt- <br /> Al <br /> t <br /> p O S/ <br /> Al �( <br /> City)State Zip Code Phone Number %, Section <br /> IT <br /> 610 s N. .SS3 Y 9Sa- 9is-DYDb TS22``��N; (circle^) <br /> � <br /> II.Type of Building(check all that apply) �E o(& <br /> ort Family Dwelling-Number of Bedrooms (1'�-f Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use s I 1191 <br /> 11 State Owned-Describe Use ElCity ElVillag ownship of utlf <br /> e <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System y eplaeement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil 11At-Grade El Single Pass Sand Filter <br /> Constructed Wetland El Pressurized In-Ground OILHolding Tank El Post Filter [I Aerobic Treatment Unit El Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter 11 Leeching 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(sl) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Eristing <br /> Tanks Tanks <br /> Septic o olding T Y- 1 rPi.44/ � <br /> robi �- wr <br /> Aec Treement Unit W <br /> Dosing Chamber <br /> 3rII.Responsibility Statement-1,the undersigned,assume responsibility for inata the POWTS shown on the attached plans. <br /> Plu ber's Name(Print lumber's Signature /MFRS- bar Business Phone Number <br /> 001 f a.l,.�s ZZZS L47Z- -LVz1 <br /> PI mbar'.Address(Street,City,State,Zip e) <br /> o?(oS- SO"'a .S - 1—("k, IA" " <br /> VIII County/Deriartment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signature tamps) <br /> Surcharge Fee) <br /> El Omer Given Reason for Denial V y G7j f/e <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Atbch compleh plain(to the County only)for the system m paper not loss than 81/1 111 inches in size <br /> SBD-6398 (R. 01/03) <br />