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Safety and Buildings Division fCmnt �'�I <br /> 201 W. Washington Ave.,P.O.Box 7162 <br /> iseonsin 53707-7162 it Number(m be filled in by CoJDepartment of Commerce (608)2663151 `�/ <br /> Sanitary Permit Application .Number <br /> In accord with Comm 83.21,Was.Adm.Code,personal information you provide ct)may be used fm secondary purposes Privacy law,sl5.07(U(m) ss(if different than mailing address) V <br /> I. Application Information-Please Print AB Information <br /> F-- <br /> Property Owner's Name PaSuxl Y Block# <br /> c O6��vi� b7-es�� *-17PO4 �«n-oi2coo <br /> Property Owner's Ma ding <br /> lingdeProperty Locations � of V- <br /> %k <br /> _LZXAL -A, Alit)%,Sectimi <br /> City,State ZipCode <br /> 1 V!5-1; <br /> Mre Number <br /> o"1 r s -rQ 5!/ 1 77 rL139 A(cTel <br /> II.Type of uilding(check all that apply) T #6 N; R I( E oc <br /> 7.1 or 2 Family Dwelling-Number of Bedroom Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village Township of V r iby <br /> III.Type of Permit: (Check only one box on line A. Complete tine B if applicable) 0---,) - <br /> A' ❑ New System If Replacement System ❑Tmatment nowmg Tank Repiacemem only ❑ Odw Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer w New List Previous Permit Number and Date Issued <br /> Before Expiration PII®ber Owner <br /> IV.Type of POWTS System: (Check all that ) <br /> Non-Pressurized In-Ground ❑ Mutual > 24 as 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 Fiber ❑Leaching Chamber ❑Drip Lim ❑Gravel-i ss Pipe ❑Other(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil A ication Ram(gpddst) I Dispersal Ares Required(sf) I Dispersal Area Proposed(0) System Elevation <br /> Sod 1 012- SfZ 9 1 ?374 <br /> VI.Tank Info Capacity in Total Number Mamficemr Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New I Existing <br /> Tanks Tanks <br /> Septic or Holding Tank OO <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume respoosbi)Yy fur baslatiatim of the POWTS shown on the attached plans. <br /> Z <br /> is Name(P in 0 / Sigma ore MP/MPRS Number Business Phore Number <br /> 14,�� ✓4�/1 I �✓/g5�/ 7/5�666b7 <br /> Plumber's Address(Street ,City,State,Zip <br /> Ze h+;e;vnl vje4k L),' <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includesGroundwater Date Ississui ent Signaur o Stamps) <br /> 11 Owner Given Reason for Denial Surrlmuge Fee) $3,25-1%v134ued IX. Conditions of ApprovaUReasons for Disapproval <br /> Much complete plans(in do Covaty maty)for the system m tape sot has than W2 a 11 inebes in size <br /> SBD-6398 (R. 01/03) <br />