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Safety and Buildings Division County <br /> 0201 W.Washington Ave.,P.O.Box 7162 UM <br /> ` isconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 9 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,aI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# Lot# Block# \Ar <br /> /C <br /> NO —\ <br /> Property Owner's Mailing Address ZO ! OZ Property Location <br /> l e� %o-d -T�h,oPcl•Gov^-L- tl� 3City,State e ne Numbeerr '� Y., SectionlG NZL Z- R J Q g ))JJnn (circl� <br /> II.Type of Building check all that apply) T 7�N; R��E o W <br /> PP Y) <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village(,Township of k <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. t6 New S stem <br /> y ❑ Replacement System ❑TreatmentRlolding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal El Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T c of POWTS S stem: Check all that apply) <br /> Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑ Mound a 24 in.of suitable soil ❑At-Grade ❑ 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 5o r 5- 9Gb 9t,D �,B i 97.5 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit �W <br /> Dosing Cha <br /> mbcr L/ / <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pgmber's Signature MP/MPRS Number B7usinLess Phone Number <br /> i N �� , 7;; 966- 1167 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 07760 Yw - weh iv- wJ 5 9 <br /> I.Coun /De artment Use Only <br /> pproved ❑ Disapproved Sanitary Permit Fee(jnc�e�undwater Date Issue l Issum gent Signature(No Stamps) <br /> Surcharge Fee) ��/pJ+ r /)?-, <br /> ❑Owner Given Reason for Denial vv <br /> IX.Conditions of Approval/Reasons for Disapproval WhirL <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />