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Safety and Buildings Division County (� <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> NVisconsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 U 9 if <br /> Sanitary Permit Application State Planl.-D.rNumber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide I V Dc <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 •RAAA JDw f ,t NP- <br /> ## <br /> Property Owner's Name Parcel# Lot Block# <br /> MftR 0L0ST1=K oto-43z5�6-5-fW 21 1 <br /> Property Owner'sMailing Address <br /> q L Property Location <br /> W-t s- ( vEAuL '/., '/., Section (00 <br /> City,State Zip CodePhone Number ,' <br /> tVVEZ F��LS VJI z C715)442L--17-75 T 4O N; RAirc <br /> E lelipe) <br /> II.Type of Building(check all that apply) <br /> V1 or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use DAA- AAP <br /> ❑State Owned-Describe Use ❑City_❑Village 5d'ownship of�)VAAP <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> g <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 /> Before ExpirationPlumber Owner <br /> ,,... 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 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.DispersalfFreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) I System Elevatiyn <br /> �0o 0,L, S60 �3i.Z �;a ° ; 2:9y.o� <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 nAW <br /> Septic or Holding Tank I (� 1 u M-t Wm cr e m <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS showm on the attached plans. <br /> Plumber's Name(Print) P hex's Si MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> n1(04g0 S.r•H. fv3, P,SI—D9WQtU_F_I Ws 61400S <br /> VIII.County/Depariment Use On <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing A a o Stamps) <br /> Approved 11 Disapproved <br /> Surcharge Fee) 4 2DD <br /> ❑Owner Given Reason for Denial •J� <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 a 11 inches in size <br /> SBD-6398 (R. 01/03) <br />