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Safely and Buildings Division County/� <br /> 201 W. Washington Ave.,P.O. Box 7162 Au'/`/J P <br /> `�seonsin Madisoa W1 53707-7162 Smilary Permit Num (m be filled hi <br /> Co.) <br /> Department of Commerce (608)266-3151 L <br /> Sanitary Permit Application State Plan I.D. Number <br /> In scrawl with Comm 83.21.W is.Adm.Code,personal information you provide 7/2/,33 <br /> may be used for secondary purposes Privacy Law,s15.04(O(m) Pmlern Address(if different Nan malDmg address) <br /> L Application Information-Please Print All Information <br /> CCounfv 011 7-2 <br /> Property Owner's Namc Parcel# Lot# 3 U Block# <br /> G( C Z-- rsC,k) 0-2 n <br /> Properly Ownc a iling Address Properly Urahou <br /> C/ ' c.,Z./ .3 C,v <br /> D 3 > fit+/%e �Md <br /> 'F. %,Secdnn <br /> City.State -I Phone Number C,\ <br /> /L,l (circ��le�,�,�.� <br /> II.Type of Building(check all that apply) T_ Q_N; R�E'<L <br /> j(1 or 2 Family Dwelling-Number of Bedrooms Zr S4M1i'sicaNsfirre' CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑Site Owned-Describe Use —' - OCity f]vdiaecAfownehip of SCS. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System �LRe lacemnt S itch, <br /> ❑ 'freannenVHoding Tank Replacement Only ❑ Other Modification to Existing System <br /> A. ❑ Permit Renewal I I Permit Revision 0 Change of U Permit Transfer to New List Previous Permit Number aM Date Issued <br /> Before Expiration Plumber Owner <br /> IV. of POWTS System: (Check all that apply) <br /> U Non-Pressurbed InTimund U Mutual > 24 in.of suitable soil 0 Mamd < 24 inof suitable soil U Att-Grade U Single Pass Sand Filter <br /> 0 Constructed Wetland 0 Pressurise]In Ground 9 Holding Tank 0 Peat Filter I I Aerobic Treamsent UNI 0 Recirculating Sand Filter <br /> U Recirculating Synthetic Media Filler 0 Leaching Chamber 0 Drip Line U Gravel-less Pipe 0 Other,(explain) <br /> V. Du' ersaVrreatmcut Area Information: <br /> Design Flow('pit) Design Soil Application Rate(gplsf) I Dispersal Area Require](sB Dispersal Area Puepwri(sf) System Elevation <br /> e)try <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Sim Steel Fiber Plastic <br /> Call.. Gallons of Units Concrete Constructed Glass <br /> NewF.xisnimg <br /> Tam Tanks <br /> Sc,xic or Holding Tam — Z <br /> Aerobic I reareir Unit rJ <br /> 17/ <br /> Dosing Chamber -- <br /> VII.Responsibility Statement- I,the undersigned,assume resp rcubdRy for installation of the POWTS shown on the attached plats. <br /> Plumber's No.(Priv 0 Plumber's Signe in MP/MPRS Number Business Phone Number <br /> U cls �!/l 9/ _3f�/`7z�6" <br /> Plumb AtlNese(Street ,City,Snare,Zip Code) <br /> VII Count /De artmcul Use Onl <br /> Approved 0 Disapproved Sanitary Permit Fee(includes Groundwater Date leeusd Worn enl Sign a No Stamps) <br /> Surcharge Fee) I/ j/)� T <br /> ❑ Owner Give.Reason for Denul -^ ST�(.Y bG <br /> IX.Conditions of Approval/Reasore for Disapproval <br /> Much complete pawn fin the County only)for the system or,paper not lees than 8I/2 x 11 inches or size <br /> SBD-6398 (R. 01/03) <br />