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Safety and Buildings Division County <br /> 201W.Washington Ave.,P.O.Box 7162 <br /> Iscvnsin Madison,WI 53707-7162f41.09 <br /> (608)26Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce 6-3151 5222 <br /> Sanitary Permit Application Stare Plan I..DD.,Nu/mber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 12 r Tlp'O <br /> may be used for secondary purposes Privacy Law,s 15.04(1 xm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information '',, <br /> Property Owner's Name 8-(O7 �P rk Y7- <br /> /toss Ge«./.vlt'e Parcel# Lot# ' Block# <br /> Property Owner's Mailing Address 036 yP/ .S"- Oak '70 O <br /> Property Location <br /> SYY algltllaq G6M ! 60v`t-(C a, <br /> City,State Zi Code —_.%s __'/., Section <br /> P Phone Number <br /> k aid e H w S S' `I 7/s 3t'4- 0877 ((circle or <br /> II.Type of Building(check all that apply) T N; R /7 E o <br /> 5r I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use C <br /> 11 State Owned-Describe Use r <br /> ❑City_❑village 9Township of 94mleH <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New S stem <br /> W Y ❑Replacement System ❑Treatment/Holding Tank Replacement only El Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision <br /> ❑Change of ❑Permit Transfer to New List Previous Perini[Number and Date Issued <br /> Before Expiration Plumber <br /> Owner <br /> 1V.T in POWTS S stem: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Mound i 24 in.of suitable soil V Mound<24 iut of suitable soil ❑At-Grade <br /> ❑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.Dig ersaV7freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rat <br /> e(gpdst) Dispersal Area Required(SO Dispersal Area Proposed II System Elevation <br /> �So • 9 .Sa y 97• iia <br /> VI.Tank into Capacity in Total Number Manufacturer <br /> Gallons Gallons of Units Prefab Site Steel Fiber Plastic <br /> New Existing Concrete Constructed Glass <br /> Septic or Holding Tank Tanks Tanks <br /> /OIO too" <br /> Aerobic Treatment Unit <br /> Dosing Chamber Led d <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for tustallatioa of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number <br /> Business Phone Number <br /> Plumber's Address(Strcet,City,State,Zip Code) ' <br /> 7760 �w 3 S— l ✓G6s�er (v z- srfgg3 <br /> V I.Coun /De artment Use Onl <br /> Approved ❑Disapproved Snitary urcharge Fee)Permit Fee(includes Groundwater Date Issued Issd g entSignatu o Stamps) <br /> ❑Owner Given Reason for Denial S300V I rD <br /> 1A.Conditions of ApprovaUReasons for Disapproval <br /> Attach Complete plain(to 11¢CII ounty only)for the 1 In on paper not Iw than gill:11 iethea in aiu <br /> SBD-6398 (R. 01/03) <br />