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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 13 <br /> Visconsin Madison,W1 53707-7162 Sanitary Pe ( Number NNuum`beer(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 7 5- <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,s 15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information n (� <br /> Property Owner's N e f Parcel is Lot# Block# VJ <br /> Ga v 4 / <br /> Property O 's Mailing Address <br /> (� L/ `U Property Location l a - C-!a 3(o O y-(o <br /> City,Str ate Zip Code Phone Number SectionA4,00 / • t <br /> v �N <br /> s s 7 ©Z 76 -�S3 _ a ircle one) <br /> r TN; R� Eor� <br /> II.Type of Buildiu (check all that apply) <br /> A1 or 2 Family Dwelling-Number of Bedrooms / Subdivision NameSM Number <br /> ❑Public/Commercial-Describe Use U / � // <br /> ❑State Owned-Describe Use ❑City ❑Vi_ llaae.0T wnshipof <br /> III.Type of Per (Check only one boa on tine A. Complete Hue B if applicable) A._ <br /> A' New stem Sy ❑Replacement System ❑Treatment/Holding 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 apF Q4 Lv <br /> JKNon-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 k—Learhing Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dia ersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevatio� <br /> o Ss 7 1 815' 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 /> Tanks Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for ipstalhation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu KMWMPRS Number Business Phone Number <br /> y u o3s7 lis ;2AS- 9� <br /> Plumber's Address(Street,City,Sta ,Zip C ) _ <br /> Coun /De artment Use Only <br /> pproved ❑Disapproved Sanitary Permit Fee includes Grou ter Date Issued Issuin gent Signature(No Stamps) <br /> Surcharge Fee) �--77�� / ) <br /> El Owner Given Reason for Denial 6?5 V` OD 0 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete Pk"(to the County only)for the system on paper not less than ails x it inches in size <br /> SBD-6398 (R. 01/03) <br />