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i—� - Safety and Buildings Division i County <br /> 201 W. Washington Ave.,P.O.Box_162 ! 13joy) y/- <br /> isconsn Madison,WI 53707 7162 Sanitary Permit Number(to be liI1ed in b Co i <br /> Department of Commerce (608)26b•315i JJ782/q' <br /> Sanitary Permit Application State Plan i D Number I , <br /> hi accord with Comm 83.21,Wis.Adm.Code,personal information you provide w0 <br /> may be used for secondary purposes Pnvacy Law,a15.04(I)(n) Project Address(if different than mailing address) + ,' <br /> i. Application Information—Please Print All Information �.q$90 Crw•+bt'rrr Lk /?� d <br /> �c� v\ <br /> Property Owner's Namc Parcel# Lot# Block# <br /> 04ab-y /hey 03A-5.33S-- 04400 <br /> Property Owner's Mailing Address Property Location Gov r -.Lo I a.- <br /> /0/ fH //rr 51 � %, /., Section 3S' <br /> City,State Zip Code Phone Number <br /> SA A./Gout? /91I1). Sr-3'14 9S;L-333 SW.3 T %I Ni R,. Il circleEor one) <br /> II.Type of Building(check all that apply) <br /> 1or2FamilyDwelling-NumberofBedrooms 3Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City^❑Village Township of Swr�,/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System <br /> y ( Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal 0 Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. - <br /> y Type of POWTS System: (Check all that apply) t <br /> f cY Non-Pressurized In-Ground 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil 0 At-Grade 0 Single Pass Sand Filter U <br /> Constructed Wetland 0 Pressurized In-Ground 0 Holding Tank ❑Peat Filter 0 Aerobic Treatment Unit 0 Recirculating Sand Filter <br /> Recirculating Synthetic Media Filter 0 Leaching Chamber 0 Drip Line ❑Gravel-less Pipe 0 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 /> yap , 7 6v3 . 64,8 43. p <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic 1 <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /COG MOO / S/ea r.- Y. <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 /> /?/cA- i'Voio/e..1 S -c-e4,,,,,Q4/. _et 1,S` S f ?ys- 56b-4'45-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ) 776p ie/k.,, 3s- wte6jr'r., li..Z- ,S1P`8TJ <br /> V111.County/Department Use Only <br /> �� Sanitary Permit Fce(includes Groundwater j Date Issued Issuin t Si • <br /> IX Approved 0 Disapproved Surcharge Fee) �p gnatu�: tamps) <br /> ❑Owner Given Reason for Denial .25D J l/9.it,{Y os <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> 7.., ,eve: . <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />