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Safely and Buildings Division County <br /> ` 201 W.Washington Am,P.O. Box 7162 <br /> iseonsin Madison,WI 53707—7162 San a`Zpeermiiitt Nuum�er(to be filled in by Cc) <br /> Department Of Commerce (609)266-3 15 1 <br /> Sanitary Permit Application State Plan LD Number_� <br /> In accord with Comm 83 21,WIS.Adm.Codc,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(I)(m) Project Address(if different than mailing address) <br /> 1. Application Information—Please Print All Information A3 S 17 Wal be <br /> PA. <br /> Property Owner's Name r Parcel# Lot# Block# <br /> _5'71_cv e. /S? 3335- CrY 60c) <br /> Property Owner's Mailing Address Property Location c <br /> city,State f�A! /., Section -g <br /> Y ryI l Zip C(u�dcO Phone Number <br /> //e— L fp�,�C— W e� / d / 3 Y?—Y03 ? <br /> 3 R�cirE or <br /> cle <br /> Il.Type of Building(check all that apply) T N; <br /> Lor 2 Family Dwelling—Number of Bedrooms _12 Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> El State Owned—Describe Use `-- ❑City_❑Village lXf'eamship of <br /> QsL�G3 tiJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ew System y El Replacement System ❑ Treatment/Holding Tank Replacement Only Ll Other Modification l0 Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Numberand Date Issued <br /> Before Exp <br /> nation Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> 114on—Pressurized In-Ground ❑ Mound>24 inof suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ l folding Tank ❑feat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filler ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe U Other(explain) <br /> V. DIS crsal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(s1) Dispersal Area Proposed(sf) System Elevation <br /> _3 '5"c) , 7 S� q 7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel or Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass' <br /> New Existing <br /> Tanks T Tanks <br /> Septic or+fe iayTank OT p.aa tr Y <br /> Aerobic Treatment Und V O" J <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' Signature MP/MPRS Number Business Phone Number <br /> W1481 G -2- z-7 e/1 k6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIJ.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui m Signat (No Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial fl� 2 rD/ <br /> IX.Conditions of Approval/Reasons for Disapproval V <br /> Attach complete plans(no the C.mnq only)fur the ,ten,nn paper uut Irss than 81/2 x 11 i.6In;in Size <br /> SBD-6398 (R. 01/03) <br />