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Safety and Buildings Division Count' <br /> m 201 W.Washington Ave.,P.O.Box 7162 u,e h e 7•f <br /> Madison,WI 53707-7162 Sanitary (Permit Number to be filled in b Co. <br /> Department <br /> tment ofIN ���n (608)266-3151 72 2 3Dr <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide /C79 &cko <br /> maybe used for secondary purposes Privacy Law,sI5.04(])(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All In rmation <br /> Property Owner's Name Parcel# 6&A%Dt# <br /> L "lock# <br /> 0,;L"3r4J-occ OI a✓rerl UAttss- ✓t /oZ <br /> 17)1 <br /> Property Owner's Mailing Address Property Location <br /> City,State Zip Code Phone Number V4, _'/., Section /d/ <br /> /Yf S-5%j CJ (circle o e) <br /> II.Type of Building(check all that apply) T_40 N; R/e E <br /> ,o 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑Cit_❑Village,0Township ofCW*1.,4P <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A.EB.. E <br /> New System y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> Permit Renewal ❑Permit Revision ❑Chnofore Expirationof POWTS S stem: Check all that apply) <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(sf) Dispersal Area Proposed(at) System Elevation <br /> So `� Sero roa 99. /5 <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 /> Tasks Tawas <br /> Septic or Holding Tank �d00 <br /> �d00 <br /> Aerobic Treatment Utut <br /> Dosing Chamber Cd 60 <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 /> Plumber's Address(Street,City,State,Zip Code) <br /> 7X60 yw y 3S we h s/e.,_ wr �`y Spq <br /> VIII.Coun /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui t Signa Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Con-6w QXc.Artok) is NOMgv4U-)! c)A 32. sy5&m �L tst�trlon) a 9G.32 t U s C�)= 9 , /5 <br /> Attach complete pleas(to the County only)for the system on paper not less than suz x rr imba in size <br /> SBD-6398 (R. 01/03) <br />