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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Q <br /> IccOns n Madison, -7162 Sanitary Permit Number(to be filled in by Co.) ✓'` <br /> Department of Commerce (608))266-3156-315 1 Ab34o9Z J <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.2 1,W is.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.Q4(1 xm) <br /> L Application Information-Please Print All Information <br /> PromrtY - --- <br /> Owner's Name Parcel# Lot# �tl Block# - <br /> 012-4575-OScr� <br /> Property Owner's Mailing Address Property Location - <br /> City,State Zip Code Phone Number - 6 /,, _a4j`/a, Section <br /> A&M crcie <br /> ssCF �n ss30/n Ili r// T L N; R /k orOD'/ <br /> Subdivision Name CSM Number <br /> ❑City_ Village OTownship of_c <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> 10 <br /> B' ❑ Change of7�rtm <br /> rt Transfer to New Lus Previous Permit Number and Data Issued _❑ Permit Renewal ❑ Permit RevisionBefore Expiration Plumber <br /> IV. Tvpe - ------1 - <br /> ---- - <br /> of POWTS System: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Mound?24 in.of suitable soil ❑ Mound<24 in of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ Constructed <br /> Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ Recirculating Synthetic Media <br /> Filter ❑Leaching Chamber ❑Drip Line Gravel-less Pipe ❑Other(explain) <br /> V. Dispersal/Treatment Area Information: — <br /> Design Flow(gpd) <br /> ;Designication Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Pr S stem Elevation( Y�So VL Tank Info Total Number Manufacturer Prefab Site SteelPlastic <br /> Gallons of Units Concrete Constructed Glassg <br /> Septic or$pldi* k+ <br /> �C ---- --_--_ <br /> Aerois Treatment Unit -- �--- <br /> Dosing Chamber <br /> VM Responsibility Statement- I,the undxienedduisunue=mlbility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) u igaatur MP/MPRS Number Business Phone Number -- ---_-- <br /> i <br /> Plumber's, rtep(iCtA AD ---- --- ---- <br /> VIII. County/De lI�! — - ------ <br /> roved Sanitary Permit Fee(' ludea Groundwater Date Issued Issu' lure <br /> App ❑ Disapproved <br /> 103 <br /> Surcharge Fee) I PL���- <br /> ❑ Owner Given Reason for Denial <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> - - <br /> F <br /> �p��COG <br /> Attach complete plans(to the County only)for the system on paper not leu than 81/2 z 11 Inches In she --- <br />