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I' �r- /::QNCj <br /> Safety and Buildings Division County C. <br /> m 201 W.Washington Ave.,P.O.Box 7162 N e -U <br /> Viscons�n Madison,WI 53707-7162 Sanitary PermitNumber(tobefilledinbyCo.) <br /> DepartmentofCommerce (608)266.3151 <br /> Sanitary Permit Application None Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide CP <br /> may be used for secondary purposes Privacy Law,sl5.04(IXm) Project Address(if ifi event than mailing address) ,..J <br /> 1. Application Information-Please Print All Information �D <br /> Property Owner's Name t Parcel n Lot p Black a <br /> I' t 6 43-2 C-1 111d <br /> Property Owner's Mailing Address, �� - Property Location <br /> IV677 �.s �'st itlt <br /> City,State / Zip Code Phone Number —y'/V <br /> 67%., Section <br /> ircleone <br /> 11.Type of Building(che all that apply) T .3 N; R E or <br /> ?k <br /> PP Y) <br /> Lor 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use �— <br /> ❑State Owned-Describe Use ❑City_ N❑Village wn <br /> Toship o <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑NewSystem replacement System ❑TrealmentlHolding Tank Replacement Only ❑Other Modification to Existing System <br /> B. 11 Penni t Rrnewal ElPermit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> �I-rV�.'T of POWTS S stem: Check all that a 1 <br /> quvon-Pressurized In-Ground El Mound 124 in.of suitable soil ❑ Mound<24 in.of suitable soil ElAt-Grade 11 Single Pass Sand Filter El <br /> Constructed Wetland El Pressurized In-Ground ❑ Holding Tank El Peat Filter El Aerobic Trealmem Unit ❑Recirculating Sand Filter 13Recirculatin Synthetic Media Filter El Leaching Chamber El Drip Line ❑Gravel-less Pipe El Other(explain) <br /> V.Dis ersaIlTrestrient Arca Information: <br /> Design Flow(g*Capwity <br /> pplication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Arra Proposed(sf) System�Elevation <br /> 3°0 -5;1-s2 c! �i`S—v / y, </ <br /> VI.Tank Infin Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons of Units Concrete Constructed Glass <br /> istingnksSeptic m Heiding00 <br /> Aerobic Treatmen <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( nQ Plumber's Signature MP/MFRS Number Business Phone Number <br /> -765/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .Bort -,C-/31 S e .J G✓ r y�72 <br /> VI .Court /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee includes Groundwater Date Issued Issuin gent Signature(No Stamps) <br /> Surcharge Fee) CD <br /> ��//�'� <br /> ❑Owner Given Reason for Denial "J(J VlJ _/ <br /> IX.Conditions ofApproval/Reasons for Disapproval <br /> ii <br /> SEP 1 620 <br /> Ansch complete plans(to the County only)for the system on paper not ins than AIR x I I inchu in i BURNETT V Vr`ffT^o1 'y <br /> SBD-6398 (R. 01/03) ZONING <br />