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Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 1344rnG <br /> �seons�n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce (608)266-3151 +7540 <br /> Sanitary Permit Application State Plan I..IDD.Number <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide 3 723 <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information 3 <br /> Property Owner's Name Parcel# Lot# Block is <br /> (/r Nfet rn 040 y3d9 01300 <br /> Property Owner's Mailing Address Property Location 6L I <br /> 971A5- Lane AMe 41 9 <br /> City,State Zip Code Phone Number —V.., —�A, Section <br /> Weh3ft✓ fn/S S9S99 lis-d<d-BJrS (ctmle0 <br /> T -W) N; R lb E or <br /> Il.Type of Building(check all that apply) ) <br /> I or 2 Family Dwelling-Number of Bedrooms Oy Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village JgTownship of OAk(ma/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement 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 inof suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Gmde ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurimd In-Ground 1�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.Dis UTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sQ System Elevation <br /> 300 1 — — <br /> Vf.Tank Info Capacity in Total Number Manufacturer Prticefab Site St el Fiber -Fa; <br /> h- <br /> Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank S a)'6 4:6d 4X S/4-4 w <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWFS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> � j-8S� 7/S A66- 4,1s7 <br /> Plumber's Address(Street,City,State,Zip Cade) <br /> 7760 , wr 3S we kv ev ti/r sq 89� <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signa t o Stamps) <br /> d( <br /> ❑Owner Given Reason for Denial <br /> Fee) 3000 1914W,05*ial `t( <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not lass than 81/2 x 11 iachn in per <br /> SBD-6398 (R. 01/03) <br />