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Safety and Buildings Division County <br /> Its a a 201 W.Washington Ave.,P.O.Box 7162 13u r n,g PL- <br /> 18 Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of COmmeme (608)266-3151 'M52 <br /> M 23? <br /> Sanitary Permit Application State Plan I.D.Nuumber <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide /�/ 7,7¢/ <br /> may be used for secondary purposes Privacy Law,s15.04(1 xm) Project Address(if different than mailing address) <br /> 1. Application Information—Please Print All Information <br /> 3 a Bass L/c ,# <br /> Property Owner's Name Parcel# Lot# ' '•T Block# <br /> 6 .4 /e N.r r e/,' <br /> Property Owner's Mailing Address Property Location <br /> r3 [✓. Ca . /7iI� <br /> City,State Zip Code Phone Number —�G, —YS Section /8 <br /> flt we ra Wt Sy843 7rf=(a7q- 9977 __//circle oyyg�) <br /> It.Type of Building(check all that apply) T '// N; R (T E oA21� <br /> Z I or 2 Family Dwelling-Number of Bedrooms Subdivision Name SM Number <br /> 2rPublic/Commercial-Describe Use C3M wY}. ,tq/e n <br /> 11 State Owned-Describe Use ❑City_❑Villagel3Townshipof Swr.NJ <br /> IIIMPOWTS <br /> it: (Check only one box on line A. Complete line B if applicable) <br /> A' System El Replacement System ❑Treatment/Holding Tank Replacement Only C1 Other Modification to Existing System <br /> B. ewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> tion Plumber Owner <br /> IV. TS S stem: Check ell[hat apply) <br /> K Non-Pressurized In-Ground ❑ Mound?24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Gmde ❑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.Dis ersaVl'reatMR!Area Information: <br /> Design Flow(gpd) Design Soil Appl�tion Rate(gpdsf) Dispersa��Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 6o,l 964 43 t%� <br /> 17A. <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> NExisting <br /> Gallons Tankks Gallons of Units Concrete Constructed Glass <br /> Tanks Tanks s <br /> Septic or Holding Tank /6,40 <br /> W <br /> Aerobic Treatment Unit <br /> Dosing Cher <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/IviPRS Number Business Phone Number <br /> /?le-le /S/e /elm /Zc�Lrat`o dt/ISBSi 7�f 866 - 4, I;- <br /> 1-1-1 > <br /> 's Address(Street,City,State,Zip Code) <br /> VII .Court /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issu7siml <br /> ❑OwneIX.Conditions ofApproval/Reasons for Disapproval <br /> NM: JUVYWGE of ,TRIS SAAnTAky fit= MIT- 15 /VrL,A Z AuOL)& Pe4M17 FprA 66*-- yAMch complete plans(to the County only)for the system on paper not leas Man 812 a 11 inches in <br /> SBD-6398 (R. 01/03) <br />