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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,W1 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> isCOnsin <br /> Department of Commerce ( ►8)2663151 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 8311,Wis.Adm.Code,personal information you provide <br /> Apt- <br /> may be used for secondary purposes Privacy Law,05.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information `Mef ROAD) O <br /> 3AMF� +AtSC <br /> Property Owner's Name Parcel# Lot# Block# <br /> i 44LtP�RT Oil-42�-Q/0 yam Lt-t- Iz <br /> Property Owner's Mailing Address Property Location <br /> 24 R L-ovw�i ?INF- L AKS- Cot i1CT <br /> =Y., Section�� <br /> City,State �7 �p� ���-r Zip Code Phone Number �•/ <br /> JrA� T IVE Vv-r 5402(c L����2`�&' /Jr80 ircle <br /> T�N; R�E o� <br /> ll.Type of Building(check all that apply) <br /> I or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name /� CSM Number <br /> Public/Commercial-Describe Use C—CAVOL. 10 pa-35Z <br /> ❑State Owned-Describe Use ❑City_❑Village Township of Tom"1 <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal 11 Permit Revision ❑Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that app <br /> Non-Pressurized In-Ground ❑Mond>24 in.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 ❑Rocirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Lia ❑Gravel-less Pipe ❑Odmer(explain) <br /> Dis mvrreatmeut Area Information: <br /> 'TYcsign Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> z 0t7 y� 4y0 1`RbS'r 2:Id P <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constn� Glass <br /> New Eastmg <br /> Tanks I Tanks <br /> Septic or Holding Tank V O ` CZ e ti <br /> Aerobic Treatment Unit 7\ <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assime responsibility for installation of the POWTS shown on the attached phos. <br /> Plumber's Name(Print) P tier's Sign MP/MPRS Number Business Phone Number <br /> DotRRF1 L AitMei r Z2. 10'1 (-115)Z?�Y-(o 60 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> M(o440 5X.q. 63 ZSLJ0FNutLL1=1 WI S4 CC!3 <br /> VIII.Coun!X/Department Use Only 1-1 4Z <br /> Di'Approved C1 Disapproved <br /> Sanitary Permit Fee(includes Groundwater Dat+e�Issued I n Agent Si (No Stamps) <br /> Surcharge Fee) �5D Svne. <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plum(to the Conoty only)far the system oa paper net less than 81/2 111 inches in size <br /> SBD-6398(R. 01/03) <br />