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Safety and Buildings Division County <br /> NVisconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 Y1 <br /> Madison,WI 53707—7162 Sanitary 58 9[0 Permit Number(to be filled in by Co.) <br /> (608)266-3151 l- <br /> Department of Commerce <br /> Sanitary Permit Application State Plan I.D.Number 010 <br /> r� <br /> r <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide —�J <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 t <br /> Property Owner's Name Parcel# 1/' Lot# Block#' <br /> Vey-0 74- 1-q-weL4 Goa ze,f / � <br /> PropertyOwner's Mailing Address Property Location <br /> Zto �f�� � �, o/a- a�-oyxx <br /> - <br /> City,State Zip Code Phone Number �`'----��`' Seaton 3L <br /> j'�llNytP-4 /tS y� W 41`f� 7P s -�� T oug <br /> VON; lE o <br /> II.Type o Building(check all that apply) <br /> 7 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number��/ <br /> ❑Public/Commercial-Describe Use K23 I ` P 113 <br /> 11State Owned-Describe Use ❑ _City ❑Village 1ITownship of 4C So.-t. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' P1 New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Permit Renewal ❑Permit Revision <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> ;K Non-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 tn-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.Dis ersalYfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(at) System Elevation <br /> Vow" gs7 0 9S, <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 y' <br /> Septic Holding Tack v Z S ` I>V"r <br /> Aerobic Treatment Unit I� <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,thea dersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI tuber's Sign re MP/MPRS Number Business Phone Number <br /> ty elS aer zz K6- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> '7 V'S Co i <br /> V_RI.Comity/Department Use Only <br /> P7 Approved ❑Disapproved Sanitary Permit Fee(inc 1 Date Issued Issuingen gnature mps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval �3 <br /> CCL <br /> BURNED <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in aau <br /> SBD-6398 (R. 01/03) <br />