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Safely and Buildings Division Crony <br /> ` <br /> an 201 W.Washington Ave.,P.O.Box 7162 y-`r-r <br /> CSIR Madison,W153707-7162 Srter,P itNumber(tohefillMinbyCc) <br /> Department <br /> m�77 (608)266-3)5) , 05 ;9-5 <br /> Department of Commerce �-tU <br /> Sanitary Permit Application State Plan I D Number <br /> In accord with Comm 83 21,W is.Adm.Code,personal information You provide <br /> may be used Forsemardarypurpeces Privacy law,s15.0Allano Project Address(ifiiffercnt than mailing address) <br /> LAppllcationlnformatioa-Please Print All lnformmima / - �r1 <br /> ropeny Owner's amu Parcelq Loth/ Blacked <br /> Propeny wners ailing Address Section PPropertycon <br /> e�� Ai <br /> A, <br /> Property L� aN�w,p// <br /> ' <br /> City,5101e Lip Code /^ Phone pNumber ir <br /> �[ q <br /> Gcoc9lcJ <br /> 11. Site of Building(check all that apply) �L RLW <br /> Y�I or Ford,Dwelling-Number of Bedrooms Somfoisvion/Name CSM Number <br /> 1:1PubbdCommereial-Describe Use _ 6 I I yA Ut r �� _ <br /> 11 State Owaed-Describe Use _.- _ . occl-Ella-orl0rownship of, <br /> iB.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A_ ;<17e S cor ❑ Replacement System ❑Treatment/Holdn Tank Refinement Only ❑ Other Modification to Existing System <br /> B. Ll Permit Renewal ❑ Permit Revision ❑Change of ❑PermitTmnsfet to New Ust Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.'1' of POWTSS stem: Check all Matapply) <br /> ,ZNon-Pressuriped In-Ground ❑ Mound>24 inof suitable sail ❑ Mound<2A inof suitable soil ❑ At-Grade ❑Single Pass Sand Filler ❑ <br /> Co..foded Wetland ❑ Pres"urbH In-Ground ❑ Holding Tank ❑PeatHter ❑Acmbic'Dra Moet Utut ❑Recirculating Sand caller ❑ <br /> Recirculating Synthetic Media Filler ❑Leeching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis rsaVI mi tment Area Information: <br /> Ihsign Flow(gpsd Desgn Soil Application RaaGgpdsQ Dispersal Area Required(st) Disperser Artie Propomd(sQ System Eld mina <br /> 602 17 1 ?-P? 1S9S yr-,5- <br /> VI.Tank Info Capacity in TotalNumber Manufacturer Prefab Site Steel fiber Plastic <br /> Gallons Gallons orlims Consulate Constructed Glass <br /> rv�. x,ianna <br /> Tonka Tnds <br /> 9aptioa Holding Tank <br /> AerabicTreetment unit �L/ <br /> Unions CM1amWn <br /> VII.Responsibility Statement- Lthe undersigned,a"reapomibility for installation of the POW IS shown on the atbeheJ plana <br /> Plumber's Name(Print) PI her'"Sig MP/MPRSNumber Business Phone Number <br /> S D / <br /> PI tu d,r,A dr.Planar,city,sate Zi <br /> VIII.County/Department Use Onl <br /> pruvW ❑ Uisappmved S°rotary Peomit De(includes Groundwater DateIssued Isswn gen Ignamte mmpe) <br /> Surcharge Fee) <br /> ❑ OwnerGiven Reason <br /> or Denial z �50� 7 f �G <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> AmcM1 eomplerc p6m ma rhe Conary ar )for she ryoh.or paper..,I—Man Sin x 11 inches in sire <br /> SBD-6398 (R. 01/03) <br />