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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 irrNC <br /> iseonsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co,)-- <br /> I <br /> o) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,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 /> I. Application Information—Please Print All Information o 7� <br /> Property Owner's Name <br /> Parcel# Lot# Block# <br /> Property 0 is Mailing Address <br /> Property Location <br /> City,State Zip Code Phone Number Akd��', ��A. Section <br /> n <br /> _ A1676 167 tee}j Zd (circle o e) <br /> li.Type of Building(cheek all that apply) T y0 N; RE o <br /> WI or 2 Family Dwelling—Number of Bedrooms Z Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> ❑State Owned—Describe Use ❑CJ IG�7 <br /> ty_❑Village Township of ekak <br /> RI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. *New System Y El Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑ Permit Revision <br /> ❑ Change of ❑Permit Transfer to New List previous Permit Number and Date Issued <br /> Before Expiration Plumber <br /> Owner <br /> IV.T of POWTS S stem: Check all that a 1 <br /> IIJon—Pressurized In-Ground ❑ Mound>_24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line <br /> ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpds;o Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 3C4--- - 7 y3z y�z q�7$- <br /> VI.Tank Info Capacity inTotal Number Manufacturer Prefab <br /> Gallons Gallons of Units Site Steel Fiber Plastic <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> Septic or Holding Tank goo <br /> eoO <br /> goo <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu er's Signature MP/MpR9 Number <br /> Business Phone Number <br /> s � <br /> c t5„ ZZ g —� 4966-.41/5 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z 766o t/w weber <br /> VII Court /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(in( ndwater Date Issued Issui ent Si re(No Stamps) <br /> Surcharge Fee) P <br /> ❑Owner Given Reason for Denial h f A/6 <br /> IX.Conditions of Approval/Reasons for Disapproval r <br /> r r�l <br /> rt r1 <br /> Attach complete plain(to the County only)for the system on paper not less than 81/2 x Il �/, <br /> SBD-6398 (R. 01/03) ZONING UNTy <br />