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Safety and Buildings Division county <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> iseons r Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266.3151 ,172 2? <br /> Sanitary Permit Application State Plan I.D.Number [ ` <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide X1' <br /> may be used for secondary purposes Privacy Law,sl5.04(l)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information 3 <br /> Property Owner's Name Parcel# Lot# Block# <br /> T,rti Heae, 01),- 4WS'-063/0 <br /> Property Owner's Mailing Address Property Location G_v it, <br /> / /oL <br /> /d 3/3 d n eQ <e- N _y, _y,I Section 3-5— <br /> City, <br /> 5City,State Zip Code Phone Number <br /> Le.ke 6-IM6 M Al. 5-Xvt6 (,57 -770 ro01circleOno <br /> T 40 N; R Eo <br /> II.Type of Building(check all that apply) <br /> VrI or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use L6-1 I C Sad <br /> ❑State Owned-Describe Use ❑City_❑VillageTownship of�hl^KSM <br /> IR.Type of Permit: (Check only one bo:on line A. Complete line B if applicable) <br /> A' R New System ❑ Relacemrnt System atmenitHolding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System; Check all that apply) <br /> Son-Pressurized N-Ground ❑ Mound>24 in.of suitable soil ❑Mound<24 in,of suitable soil ❑ At-Grade ❑Single Peas Send Filter ❑ <br /> Constructed Wetland ❑ Pressurized M4,round ❑ 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(sl) Dispersal Area Proposed(sf) System Elevation <br /> �/S o4i3 & q 8 93,`f <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 /000 /000 slaw <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /?"e% Ay.-in <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J 77,6o F6 3 We 6s�P� f�v1 s`f F193 <br /> VII oun /De artment Use Only <br /> OrApproved ❑ Disapproved Sanitary Pernit Fee(iq ludes Groundwater Date Issued Issuing ant store tamps) <br /> Surcharge Fee) <br /> ❑Owner Givrn Reason for Denial 77ff <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Altnch complete plans(to the County only)for The system on paper not kas than 8112 x 11 Inches In size <br /> SBD-6398 (R. 01/03) <br />