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Safety Wa and Buildings Division County�f <br /> 201 W. Washington Ave.,P.O.Box 7162 /L\l <br /> `�aconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Cc) <br /> rartment Of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan LD Number <br /> In accord with Comm 83 21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(1)(m) Project Address(if different than mailing address) <br /> 1 <br /> I. Application Informertion-Please Print All Information q9�j / //e 9/t P47 1,11- <br /> T <br /> �L <br /> �P ert Owner's Name Parcel# If7 LL; #(�C Block# <br /> :ejhv -E J Udal4-�A `tlS 1 res 0tLT -9�Sb -oi foo <br /> Property Owner's Mailing Address Property Location <br /> moo• aRS <br /> Q Statrt Zip Code Phone Number `A• �A• Section <br /> T✓ / N.. RL�EcIe W <br /> F�',npmbhc/Commercial <br /> ype of Building(check all that apply) <br /> or 2 ly DwellNumber Use f Bedrooms Sub "n1Ntaune SM 5,-5so-Describe Use QQ11 /,�/7_ <br /> State Owned-Describe Use.----- DCi yElVillage ICTownship of e-e4an <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑ New System y eplacement System ❑Treatment/Holding Tank Replacement Only li(O r Modification to Existing Sys[e <br /> B J Permit Renewal ❑ Permit Revision IJ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner "l Os'R t" �-] <br /> kIV.T e of POWTS S stem: Check all that a I Jl t� J� / <br /> .Non-Pressurized In-Ground ❑ Mound>24 inof suitable soil ❑ Mound<24 in,of suitable soil 0 At-Grade ❑Single pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> Reairculatmg Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V. <br /> His [ment Area Information: <br /> Design Soil Application Rate(gpdso Dispersal Area Required(st) Dispersal Area Proposed(so System Elevation <br /> /a e SS <br /> VI. 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 /> S Holding Tads I <br /> Ier <br /> zspW/ (ese —� <br /> Aerobic lmamUm <br /> mm t 1 -' <br /> )osing Chambe t e`nr <br /> VII. Responsibility Statement- 1,the uRderifigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pri t) Ph MP/MPRS Number Business Phone Number <br /> N e(s2zr>z ��s SK sir <br /> Plur tuber's Address(Street,City,State, ip Code) <br /> 9d 3� llJe(os �r <br /> 1 VIII.County/Department Use Onl <br /> iJ(Approved ❑ Disapproved Sanitary Permit Fee(includes GroundwaterDate Issued Issum ge ignatur Stamps) <br /> Surcharge Fee) ry �50� ' � O� s <br /> Li Owner Given Reason for Denial e� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> DI �� <br /> a tV&Ji <br /> � <br /> JUL ? 9 L <br /> i) <br /> cuuj <br /> Attach complete plain(to the County only)for the system on paper not leu than BIR x 11 inches m aiN TT �Y UA 1TY <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />