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-71 <br /> Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 /a c- <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled <br /> NVisconsin <br /> in by Co J <br /> (608)266-3151 <br /> Department of Commerce State Plan I.D.Number <br /> Sanitary Permit Application <br /> in accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide project Address(if different than mailing address) <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) J <br /> I. Application Information-Please Print All Information <br /> Parcel# Lot# B ock# <br /> Property Owner's Name <br /> r <br /> petty Owner's ailing Address Property Location <br /> 7 A, G/ 0 Q � 'b, „''/y Section <br /> City,S to Zip Code [� Phone Number (circl <br /> 8/40 T'/�I /+ �r nJ SS� T Tex; R�_E o(2!) <br /> N; <br /> II.Type of Building(check all that apply) Subdivision Name CSM Number <br /> l or 2 Family Dwelling-Number of Bedrooms i <br /> ❑Public/Commercial-Describe Use <br /> ❑City_❑VillagcXownshipof <br /> ❑state Owned-Describe Use <br /> III.Type of Permit: (Check only one box on Hue A. Complete line B if applicable) <br /> A' ❑New System ElReplacement System ElTreatment/Holding Tank Replacement Only ❑other Modification to Existing System <br /> List Previous Permit Number and Date Issued <br /> B. [IPermit Renewal ❑ Permit Revision L1 Chan ge of ❑Permit Transfer to New <br /> Before Expiration Plumber Owner <br /> 9IpV..Type of POWTS System: Check all that apply) <br /> 11 <br /> vNon-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.Dia ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System <br /> t� • ✓I <br /> VI.Tank Info Capacity in To Number Manufacturer refab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank o0 <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 <br /> MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VI"pproyed <br /> rtment Use Otil <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issui t Si (No Stamps) <br /> Disapproved Surcharge Fee) �tWOwner Given Reason for Denial <br /> IX Conditions of Approval/Reasons for Disapproval <br /> RdU%51V­i%) chp.,yl►'� )APRS <br /> Attach complete plans(to the County only)for the system on paper not leas than 81/2 x 11 inch"In size <br /> SBD-6398 (R. 01/03) <br />