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Safety and Buildings Division County <br /> NVisconsi <br /> 201 W.Washington Ave.,P.O.Box 7162 a Y K-C 4 — <br /> n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <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,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner'sarae r - Parcel# Lot# Block# <br /> 4Y � <br /> Property Owner's Mailing Address Property Location <br /> 31Z Ajobl A� t S <br /> City,State Zip Code Phone Number <br /> -� '�S Y, Section <br /> VVt[nnP� lS V )1 SS4ZZ_ �b3 ]oC�eZy7T /N; R ircor� <br /> II.Type of B (ding(check all that apply) *� <br /> 1 or 2 Family Dwelling-Number of Bedrooms rf—❑ Subdivision Name CSM Number Public/Commercial-Describe Use LOT /c5fn.L/Z� 19 //5- <br /> State Owned-Describe Use ❑City ❑Village;ffTownshipof #"eejLo),A <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> FLBeforc <br /> New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Expiration Plumber Owner <br /> of POWTS S stem: Check all that apply) <br /> J on-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑ Mound<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.Dia ersal/Treatment Ares Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> ao z So 9 ,/, ,s-- <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 /> Talcs Tanks <br /> Septic o Holding Tank rn I <br /> Aerobic Treatment Unit V <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the an ersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu ber's Signal MP/MPRS NumberBusiness Phone Number <br /> WS 1}QF S 2 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> S d — CJ, p� <br /> VIII.Coun /De irtment Use OnlyO <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater I Date Issued Issuin gent Si a o Stamps) <br /> 11 Owner <br /> Fee) <br /> Owner Given Reason for Denial 0- <br /> IX <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> JUL 1 � <br /> Attach complete plans(to the County only)for the system on paper not kss than alt z 11 inches in AC <br /> ' Izo/v/NG UN� <br /> SBD-6398 (R. 01/03) <br />