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ON COMPUTE-R/S( E sildings Division County/� f/ <br /> t 201 W. Washington Ave., P.O. Box 7162 eU ej o'1,Jf <br /> IsconsIn Madison, WI 53707-7162 Sanitary <br /> QPermit Number(to be filled in by Co.) <br /> Department of Commerce (608) "t� <br /> 266 3151 USZc1 <br /> Sanitary Permit Application State Plan I.D. Number ' 1 r <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide /2�0070 (�/�--�"J <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 (- #31D) <br /> Property ._, <br /> Owner's Na J0 /, Jc ) <br /> ( '�' Parcel# Lot# Block# <br /> I�i c h A-r'c /4- o 9, a 5---c2 SV 62 sr ex--) <br /> Property Owner's Ma iling Address led <br /> Property Location <br /> / <br /> 5 6�d� S cj/' e//) 1 S C 14, t 4,Section <br /> City,State / Zip Code Phone Number <br /> G r A-45 414 Cot^ sy8V d eg r�'�,25 vZ 7 (circle o ) <br /> II. Type of Buildingcheck all that apply) T N; R E or V <br /> or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑ State Owned-Describe Use ❑City ❑Village owfship of <br /> eZOC)c / Jer <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System ,Re lacement System <br /> y p y ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Pre 4v0ious Permit Number and Date Issued <br /> Before Expiration Plumber Owner (D 7/ (. /V 969) e//o183 <br /> IV. Type of POWTS System: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Mound > 24 in. of suitable soil K 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 Flow(end) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �fS—U 4/SD /00/ <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 / `/ <br /> /a 0 / t: S-6O»'t 2 c.a.'ex <br /> Aerobic Treatment Unit <br /> Dosing Chamber /Ooo //�� / C ISt<cm re Gas 6 <br /> 6�, Ca . <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility or installation of the POWTS shown on the attached plans. <br /> Plumber's Name Prin t) Plumber's Signs tore MP/MPRS Number Business Phone Number <br /> AUSle A ''A6 /, 614- - -27 7/ 351 7-z 7 <br /> Plumber's Address(Street ,City,State,Zip Code)i e3r)e /5/ Sir'e G4.1-7- -.6-7//c>'�� <br /> 7 <br /> VIIIII. County/Department Use Only <br /> B1 Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A Signatur o Stamps) <br /> Surcharge Fee) 300 y ' ��//� / r <br /> ❑ Owner Given Reason for Denial �l0 <br /> IX. Conditions of Approval/Reasons for Disapproval J <br /> /gib j E: Ex i s-64- (-1�.Oru(r• TA04.5 Gav•ev'�er,( £o Ail ST/S T f. <br /> • <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />