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SiteIy and B&mldines Division County l <br /> jDepar�tment <br /> m '-01 R'. R'ashing(on Ace., P.O. Bos 716' uovt f <br /> e:OfCosin Madison, W1 53707 -7163 Samar emtn Number Ito be filled in bo Co.) <br /> mmerce (608) hh-3151 e 7&, <br /> Sanitary- Permit Application $tart LD Number T <br /> In Accord with Comm 8311,0.1s.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1)Int) Project Address(it ditt'crent than mailing address) <br /> L Application Information-Please Print All Information <br /> aA: <br /> Property Owner's Name <br /> a��a0 Lone Prime Rip. <br /> Parcel x Lax Block x <br /> Vi 00 143,,q oil >ee <br /> Proper- Owner's Mailing Address <br /> Properly ocauon ( OV <br /> LE• <br /> City.State Zi Code �' Section Z 9 <br /> P Phone Number <br /> Jj (circle ) <br /> 11.T}pc of Building(check all that apply) T "!D c R �6 E ore <br /> I or 2 Family Dwelling-Number of Bedrooms :3 Subdkisio Name CSM Number <br /> ❑ Public Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village ATownship of f. <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New$ sttm <br /> y� ❑ Replacement System ❑ Treatment:Holding Tank Replacement Only ❑ Other M ification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Lut Prewo s Permit Number and Date Issued <br /> Before Expiration ❑Permit Transfer to New <br /> Plumber Owner <br /> IV.Tvpc of PO%kTS System: Check all that apply) <br /> f9 Non-Pressurized In-Ground ❑ btound>24 in.of suitable soil ❑ Mound<24 in.of sortable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Welland ❑ 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 p ❑Other(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> ZScpticur <br /> (gpd) Design Soil Applicat®RaeIgpdsl) ersal Area Required(51) Dispersal Area Proposed(sf) S stet Iry ton <br /> Y3 4'". �,���? <br /> nfo Capacity in rg Z.e <br /> Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Concrete onstructed Glass <br /> New ExistingTanks Tanksmg Tank / _ y(� e <br /> ent Unitr <br /> %IL Responsibility Statement- 1,the undersigned,assume responsibility(or installation of the POskTS shown on th attached plans. <br /> PI nber's Name(Print) Pto is Signature MP D1PR5 Number Business Phone Number <br /> r L'{�Ca� r� 2�96-/ (714 'y <br /> Plumber's Address Street,City,State,Zip Code) <br /> VIII oun[v De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater D e' ski -u.ng. ignatur Stamps) <br /> Surcharge Fee) s¢ n�O p� <br /> ❑ Owner Given Reason for Denial (� p( <br /> 1\.Conditions of Approval/Reasons for Disapproval <br /> 1 APR 6 <br /> 2004 <br /> BuRNE . <br /> zO�NGU"7y <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 a 11 inches in lsizc <br /> SBD-6398 (R. 01/03) <br />