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_ Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 V(`/e' <br /> ?eNcosinMadison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Dent of Commerce (608)266-3151 C <br /> Sanitary Permit Application Sta Ian I.D.Ter <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide Y tea• W <br /> may be used for secondary purposes Privacy Law,at 5 04(I)(m) Project Address(if different than mailing address) ( \ 1 <br /> I. Application Information-Please Print All Information a <br /> rope <br /> PO '7 wner's Na e /L2 Parcel# Lot# Block# <br /> �• 33 07- 2 -2 /,-,�77-,Z o3 aa� D/l <br /> Property Owner's Mailing A�d,d�rerProperty Location <br /> 7 2 2" Al <br /> City,State Zip Code Phone Number —�A, P 'A• Section <br /> 1I Ali b6 7W263 /'7/ST N; R (circle ) <br /> 11. pe of Building(check all that apply) J�E ok) <br /> ❑ Subdivision Name�T/7 CSM NumberIort Family Dwelling-Number of Bedrooms ��//�� 7T� 385�7 <br /> ❑Public/Commercial-Describe Use C6 {^� • V <br /> ❑State Owned-Describe Use ❑City_❑Village?township of 061IL19^4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y El Replacement System ❑Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System <br /> B• ❑ Permit Renewal ❑ Permit Revision El Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that app,1 <br /> [ Non-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 Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> )f5-6 - S 900 9/6 ?736 <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 ,ase ,+ fes^ ' fi,(s r <br /> Aerobic Treatment Unit if/�•/ •+r/ll lV7�s <br /> Dosing Chamber <br /> VI 1.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI er's Nam(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 7/5866-8o 10 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z o <br /> VIII ount /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin Signatur Stamps) <br /> ❑ Owner Given Reason for Denial l/ �//•Lb� ✓/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less than 81/2 x 11 inches m size <br /> SBD-6398 (R. 01/03) <br />