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—_—_ 01 W Washm•tan4ve..PU Sae -Ih- ; . /J U/•i.YC-�{-� <br /> 8K.sconsin %Iadison W 153707-716' Sanitary Pennit Number Ito be filled in by Co.) <br /> (608)266)151 <br /> Department of Commerce <br /> Sanitary Permit Application Stare Plan LD.Numbs <br /> in a¢ord with Comm 8721,Wm Adm.Code,personal information you provide ' s , <br /> may be used far secondary purposs,Privacy law,a]5.04(lxm) Project Addr ser(if i ifferent that meiliag addtma) <br /> W. (3en�� 1 Lttue_ <br /> I. Application Wormation-Please Print AB Information <br /> Property Owner's Name Paled# Lot# Bloch# <br /> /�att Cl1r� t.oC1- 0)-4-3104 02 s?7oo <br /> Property Owners Mai]mg Address Property Location 'oV'�• CO 1 3 <br /> g ' �qo— sem. 4 <br /> City,Stale Zip Code Phone Number U —Y., _'/., Section <br /> (Sinilw = . S4?3o 7/S 116) ' I Tz9 29 N. R ' (cirtale <br /> T-a <br /> II.Type of Building(check all that apply) U <br /> Q] Subdivision Nance CSM Number <br /> 1 or 2 Family Dwelling-Number of Bedrooms 7 <br /> Public(Commetcial-Describe Use <br /> ❑State Owned-Describe Use QCity Qvigage Oroweship of J ik <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 9-Replacemcnt System ❑TrentmentMalding Tank Replacement Only 13 Otho Modification to Existing System <br /> B. ❑ Permit Renewal 13 Permit Revision 13 Change of Permit Ttmsfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POINTS System: Check all that a 1 <br /> T,Non-Pressurized(a4vaund 13Mound>24 in of suitablesoil 13 Mound<24 in.of suitable soil ❑Atxmde ❑Single Pass Sand Filter 13 <br /> Consmrcted Wetland ❑ Pressurized in-Ground D Holding Tank ❑Peat Filter ❑Aerobic Treaunent Unit ❑Recirculating Sand Filter O <br /> Rwitcdating Synthetic Meda Filter ❑Leaching Chamber 13Drip Line 13Grovel-ess Pipe ElOther(explain) <br /> V.DispersaVrresitmanut Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(Wili f) Dispersal Arta Required(sf) Dispersal Atm Proposed(at) System Elevation <br /> 6 00 . I I /,�00 0- 13 9,5.07&- 9S.Ap <br /> VI.Tank Info Capacity in Total Number MamsfatYurer Prefab Site Steel Fiber Plastic <br /> Gallons; Callow of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Scptio m Hokkng Tank (jS0 1 1•-,S 0 ( G. K <br /> Amin.Tteneem Unit <br /> Dosing Chumber <br /> VII.Responsibility Statement- 1,the undersigned,moms responsibility for installation of the POINTS shown on the attached plans. <br /> Plumba's Name(Prim) P 's Si MPAORS Number Business Phone Number <br /> UA, 74*MMNUW <br /> Plumber' Address(Sweet,City,State,Z CAN <br /> (I "t <br /> VIII.Couo nt Use only <br /> Approved Disapproved Sanitary Permit Fee includes,Groundwater Date Issued Lssuin t Si (No Stamps) <br /> Suroharge Fm) 2�"° 17.P o5 <br /> ❑Gwen Given Reason for Deaiel �' <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the Cooaty Daly)for the snhm on paper nor kora than 812 s 11 inches in sine <br /> SBD-6398 (R. 01/03) <br />