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Safety and Buildings Division County �{� <br /> 201 W.Washington Ave.,P.O.Box 7162 6 LA Y Ir / f <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Nu nber(to be filled in by Co.) <br /> Of Commerce (608)266-3 15 1 10e I 2-2� <br /> Sanitary Permit Application State Plan I D_NL]i nber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 13 S 3 90 <br /> may be used for secondary purposes Privacy Law,515 041 Project Address(i(different than mailing address) <br /> I. Application Information-Please Print All Information IOS <br /> Property Owner's Name Parcel# [.of# Block# <br /> c be U 3y-/ LIQ-n % 1517119 <br /> Property Owner's Mailing Address Property Location <br /> / zoo@ __f rd z ov[ota <br /> City,State 11 Zip Code Phone Number - �h, - 'A. Section z M <br /> GGaulSbin� 5�8 �6 —1— �lJ/L5 circleone) <br /> S-7 U <br /> It.Type of Building heck,II Subdivision that apply) T on Name CSM Number <br /> R� i E or W I <br /> or -z <br /> � <br /> 0, <br /> ❑Public/Commercial-Describe Use —�r- <br /> ❑State Owned-Describe Use ❑City_❑ S'o <br /> Village wnshipot/.L a c/t <br /> III.Type of Permit: (Check only one box on line A. Complete line R if applicable) <br /> A' ❑New System eplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modifical on to Existing System <br /> B. 13 Permit Renewal 11 Permit Revision ❑Change of 11 Permit Transfer to New <br /> List Previous Perm t Number and Date Is's'ued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑ Si igie Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground VRolding Tank ❑Peat Filler ❑ Aerobic Treatment Unit ❑Recircl aling Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersairrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) ystem Elevation <br /> 3Co — — 97, L> <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Sit Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constirfeted Glass <br /> New Existing <br /> Tanks Tanks <br /> Selow11 IIolJins Ta '14- <br /> Aerobic rocaunciii <br /> Aerobic'rrcaunenl Unit <br /> Dosing Chamber <br /> II.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW]S shown on the anta shed plans. <br /> P umber's Name 111 11 Plumber's Signature MP Number Bu 'ness Phonc Number <br /> tumc <br /> r gAddress(Street,City,State,Z.i ode/j <br /> 1j-6 � asf. G`UC �. .j yit <br /> VIIL County/Department Ilse Only <br /> Approved ❑Disapproved Sanitary Ptrmit Fee(includes Grouni t limo Issued Iss 1i A• t.l'ignnit o Stamps) <br /> Surclmrge Fee) Q�-7)y�- / <br /> ❑Owner(liven Reason for Ucnial � tJw ___ �/�Om <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plena(to the County only)for the system on paper nut less Than 81R r 11 inches in siz <br /> SBD-6398 (R. 01/03) <br />