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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 63u e n-eYf <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 /�J Cj �_ <br /> Department of Commerce I IC Z� <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide _6_c <br /> maybe 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 44 <br /> e_44-7 D(r-; <br /> Property Owner's Name Parcel# Lot# Block# <br /> Pfd f 0)400 <br /> Property Owner's Mailing Address Property Location <br /> env' is /!✓c N o v,t, (o <br /> City,State Zip Code Phone Number -- — ' _/4, Section 3 <br /> (circle e) <br /> T N; R _o <br /> t� <br /> II.Type of Building(check all that apply) <br /> X1 or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village Township of sw fx <br /> III.Type of Permit; (Check only one box on line A. Complete line B if applicable) <br /> A. ❑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.T of POWTS S stem: Check all that apply) <br /> ANon-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 ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design FloCw_(ggpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) 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 Existing <br /> Tanks Tanks <br /> Septic or Holding Tank le04 <br /> Aerobic Treatment Unit <br /> Dosing Chambcr <br /> VR.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached pions. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> plek #60 /eros I L8� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ?76 0 /fµ- <br /> II.County/Department Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu ng, gent Signature(No Stamps) <br /> Surcharge Fee) _ (/ , <br /> ❑Owner Given Reason for Denial d� 6D /0`�� `7 1 n^l� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than gin x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />