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Safety and Buildings Division County <br /> `VV& W 201 W.Washington Ave.,P.O.Box 7162 Q vn <br /> Madison,on,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 551 zo9 <br /> Sanitary Permit Application Sate Pian I.D.Number Q <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal infomation you provide <br /> may be used for secondary purposes Privacy taw,at 5.04(1$m) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Informatioat n V807 6/4t.FF LK <br /> Property Owner's Name Parcel# Lot# Bl7ock# <br /> 6/en Scliwltke✓atfh <br /> Property Owner's Mailing Address Property Location &V t 60T <br /> 38D W;Vwod Cr Cl <br /> City,State Zip Cade Phone Number - -A --/., Section <br /> Sf: /wo.1�t^r ,f1 ,S•So 81 (.S/-f JO-/O/S� let rcle�e) <br /> T 4a N; R /7 Eo <br /> II.Type of Building(check all that apply) <br /> NI or 2 Family Dwelling-Number of Bedrooms 4 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑VillagegrTownshipof tlsston <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 8 <br /> A. 1 New System y El Replacement System ❑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 /> D(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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 1 . 7 1 v3r sv.W <br /> VL Tank Info Capacity in TotalNumber Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Consuucted Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Toed, good 6W t/ x`�� <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 /> lisfe'A h'o /cr.aS /tom_,e44® !{ ok-Lsfrs/ /s-S66,- er/r7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 *L 3-r- wcbsfe� �✓L SS°�93 <br /> VIII.County/Department Use Ord <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing nt S store ps) <br /> Surcharge Fee) ,, <br /> El Owner Given Reason for Denial �r,J(/ p r6 fYv/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not Ins man 8112 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />