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Safety and Buildings Division County .t�f <br /> Asconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 U R N C `1 Madison,WI 53707-7162 Sanitary permit Number(to be filled in by Co.) <br /> (608)266-3151 7 &z ` <br /> Department of Commerce JV <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Coda personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(l xm) Project Address(if different than mailing address) i fti <br /> I. Application Information—Please Print All Information �J <br /> 3095 Z J7u11+'ou00, a <br /> Property Owner's Name Parcel N Lot d 5 Block 8 <br /> 1 GN 6p-L. i k 1 ROT LAG 037 -5218 -o4 -too <br /> Property Owner's Mailing Address Property Location <br /> (PC) 8c) DALL.A-5 LAO Goy LO-V.3 <br /> City,State Zip Code Phone Number Jr Section 16 <br /> pt_-{rroo !zeal�jAu�> <br /> 11.Type of Building(check all that apply) T41 N; RE orgy/ <br /> P(l or 2 Family Dwelling—Number of Bedrooms 3 Subdivision NameCSM Numbe <br /> ❑Public(Commemial—Describe Use vol. lb Q:3 f55-L51 <br /> ❑State Owned—Describe Use ❑City_❑Village Township of�)tilL55 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, JKNew System ❑Replacement System y ep yst ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> SIV/.T of POWTS System: Check all that apply) <br /> �r Non—Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constmcted 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 rsaVCreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation e <br /> 45 1 --71o43 LP461 95 .5 <br /> VI.Tank Info Capacity in Total Numbs Manufacturer Prefab Site Steel I Fiber Plastic <br /> Gallo" Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> tanks Tanks <br /> Septic or Holding Tank 00 two <br /> ' 5KAQ <br /> Aerobic Treatment Unit <br /> Doting Chamber <br /> VIL Responsibility Statement-1,the PI s Si tuundersigned,assume responsibility for installation of the POWTS showu on the attached plans. <br /> Plumber's Name(Print) m WEIMPRS Number I Business Phone Number <br /> T6,) FRtel��u. 22�5/�4 115�(p3�-3dZU <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 141 15"ll AV 5P.RR0rJ w—T 5A- <br /> VIII.Cozen /De art hent Use Only <br /> lir'Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater1?ate Issui t Signature tamps) <br /> Surcharge Fee) <br /> 11 Owner Given Reason for Denial � � � r] -�+M <br /> IX.Conditions of Approval/Reaoo <br /> ss for Disapproval /SStKa( '427105 <br /> R&01s(pl) 'Nj')5Fat5 P/.(In41.eY, <br /> permit Ex pws 4l3-7)07 <br /> Attach eompleh pians(to the County only)for the ayatem an paper not less flan 91/2.11 inches i.6. <br /> SBD-6398(R. 01/03) <br />