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Safety and Buildings Division County <br /> Visconsin <br /> 201 W. Washington Ave., P.O. Box 7162 ' C4r^.)Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4{,p 5 / 7co <br /> Sanitary Permit Application State Plan I.D. Number-moo 1 <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Information <br /> Property Owner'sm <br /> ae <br /> {q ,I Parcel# Lot# Block# <br /> 40Y a /17) CC AIJAJ 0l,3_4/0j,3-3-0/_(00 IvE-NE_ <br /> Property Owner's Ma fling Address , Property Location <br /> '� <br /> /V <br /> City,State Zip Code Phone Number , "Ti, '}�i.Section —2 z <br /> 2_ r LJ g `� y'- 255 .4circleoe <br /> II.Type if Building(check all that apply) T f- N; R 5 E or <br /> ,K1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑ Public/Commercial-Describe Use ---� - <br /> ❑State Owned-Describe Use ❑City_❑Village 754fownship of <br /> (3vT— <br /> III. Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> A. '.New system y El Replacement System ❑ Treatment/Holding Tank Replacement ONy ❑ 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 /> ,KNon-Pressurized In-Ground ❑ Mound > 24 in.of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Wedand ❑ 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plas[Ic <br /> Gallons Gallons of Units Concrete Conswcted Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Ftuldixg7aok <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(Pri t) Plumber's Signa one MP/MPRS Number Business Phone Number <br /> 6 1411111 � --z 2! 7L ZZivy -�zy�. <br /> Plumber's Address(Street , City,State,Zip Code) <br /> VIII, County/Department Use Only <br /> Wl<pproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin a Signature(N mps) <br /> (J n . <br /> ❑ Owner Given Reason for Denial Surcharge Fee) Apt <br /> IX. Conditions of Approval/Reasons for Disapproval <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 />