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Safety and Buildings Division County <br /> Visconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 V Madison,WI 53707-7162 Sanitary?emit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4`98 32 VJ <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,a15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> 4607 <br /> Property Owner's Name Parcel# Lot# Block# <br /> 74mie i6mrom o — 3oa-6r -zoo <br /> Property Owner's 240t, <br /> MailingrNAddress Property Location <br /> City,State ' r Zip Code Phone Number W �A �A <br /> = IJ = Section 13 <br /> u. Pyk w • SO ImV& 341 ,L(circle <br /> TSN; R�Eo& <br /> ll.Type of Building(check all that apply) <br /> 81 or2Family Dwelling-Number ofBedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> [I State Owned-Describe Use ❑City ❑Village$Township of^e#AJtW <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 19 New System y 11 Replacement System ❑Treatment/Holding Tank Replacement Only [I 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 /> yr Non-Pressurized In-Ground ❑ Mound>24 in,of suitable soil ❑Mound<24 inof suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized rin-Ground El Holding Tank [I Peat Filter 11 Aerobic Treatment Unit Recirculating Sand Filter <br /> d ❑ <br /> Recirculating Synthetic Media Filter p Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) (;- k," Is <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevatigp.� 70 <br /> 456 f 5 90c> g4.,00 <br /> VI.Tank Info Capacity in TotalNumber Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding'ran, <br /> Aerobic Treatment[Unit W✓ <br /> Dosing Chamber !M <br /> VII,Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Na a(Print) be's Si tore MP/MPRS Number Business Phone Number <br /> C I W a 4 t �' 0833 In -J7c,6, <br /> PlumbOr's Addreyf(Street,City,State,Zip Code <br /> 6"^x IA2 <br /> II.Coun /De artment Use Only <br /> Approved ElDisapproved Sanitary Permit Fee(includes Groundwater Dale Issued Issuir g a Signatu o Stamps) <br /> Surcharge Fee) Zs�� Ol0 <br /> ❑ Owner Given Reason for Denial (p <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less than 81/2 x I I inches in sin <br /> SBD-6398 (R. 01/03) <br />