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Safety and Buildings Division County n <br /> Visconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 &u V h-e"�`— <br /> Madison,WI 53707-7162 Sanita Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 IR I0( <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(I)(m) Project Address(if different than mailing address) <br /> L (� <br /> Application Information Print All Information -.,.(�-� S �,flfl6 e/ .Sw CS'�/ ?c� `0 <br /> Property Owner's Name T� Parcel# Lot# j Black# r� <br /> l3;// Fa/e c - 4LO 091- 700 " \ <br /> Property Owner's Mailing Address Property Location /•O t co T g , <br /> 4,411 !'arevfew A"e. S. C7 <br /> City,State Zip CodeSectio <br /> Phone Number �• circle <br /> onn7 <br /> l <br /> .se. /ata.. / s'YI q/, SS/o,t- b s/_G 9 9- 7o S7 T 5'D N; R E oeCW/ <br /> II.Type of Building(check all that apply) <br /> I®1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use ISM V, E .-so <br /> ❑State Owned-Describe Use ❑City_❑Village&ownship of ✓akc/Cse 7 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Re placement System y p y ❑ Treatment/Holding Tank Replacement Only El 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.Type of POWTS S stem: Check all that apply) <br /> 'Non-Pressurized In-Ground ❑ Mound>24 in.ofsuitable soil ❑Mound<24 in.ofsuitable 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,Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpds f) Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation <br /> Oso . 7 (o e13 6 y e 9`/..3 <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 �QBO �QGQ S�Qw <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ?,c/c- f/Q �,.,f Z,-/.a��' <br /> Plumber's Address Street,City,State,Zip Code) <br /> .)- -7-76 0 /7-' 6ae 6s for c✓T s 893 <br /> VIII,Count /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing a ignature Stamps) <br /> Surcharge Fee) a � ,ire <br /> ❑Owner Given Reason for Denial YP 7 �!/ �( <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not las thin 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />