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Safety and Buildings Division County �f L <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> Asconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 51 D <br /> Sanitary Permit Application StateyP D. Number <br /> In accord with Comm 83.21,Wis.Adm.Cab,personal Information you provide (nrW <br /> may be used for secondary purposes Privacy Law,sl5.04(lxm) Projecn Address(if different than <br /> ^mulling address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name/ OP71Teta/f1.2-af0-!S•'11-t as o/Bl ock <br /> DiQ 't4bc.r �/?g6 X n/4t9t'J <br /> Property Owner's Ma fling AdProperty Location <br /> q17 6 dres��� r <br /> Si, u,Section <br /> City,State Sc.. Zip Code q Phmte pNumber <br /> 9r N n <br /> /AJ �`�'�/ �' 7 ���7trcle ) <br /> I1.Type of Building(check a6 that apply) T N; R ? Eo t <br /> 9 1 or 2 Family Dwelling-Number of Bedrooms � Subdivision Name CSM Number <br /> ❑ Public/Commercial-Describe Use --4%&d rJUIA W1161M 01 <br /> ❑State Owned-Describe Use ❑City_❑Vi lage IATownship of��k5p�► <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New Systemacemem S ❑Trdhnerx/Hdd" Tank <br /> �Repl System ag Replaatnem Only ❑ Oder Modification to Existing System <br /> B. ❑ Permit Rerewal ❑ Permit Revision ❑ change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Phmber Owner <br /> IV.Type of POWTS System: (Check all that ) <br /> 7" Non-Pressurized In-Graved ❑ Mound 2i 24 in.of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Wedand ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat FBter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Graved-less Pipe ❑Other(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Reeptired(s0 Dispersal Area Proposed(sf) System Elevation <br /> 34V • 7 4z W g rq-X3 13 V 7 <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 /> Tants Tanks <br /> Septic or Holding Tank 8� r m_ / <br /> Aerobic Treatment Unit �V <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,ata®e responsilihility for dim of the POWTS shown m the attached plans. <br /> PI is Name(Prin t �' `s Signe MP/MFRS Number Business Phone Number <br /> /afdel <br /> Plumber's Address(Street ,City,State,Zip <br /> Z7ZZO VYiylae V�G�9�t/ �✓i Sy� <br /> VIII.Cornet /De ent Use Only <br /> Approved ❑ Disapproved Satutary Perm Fee(includes <br /> (includdes Groundwater Date issued',,t Issuin nt Sign No Stamps) <br /> 11 Owner Given Reason for Denial S 3 J '� (,µ. <br /> IX. Conditions of Approval/Reasoras for Disapproval <br /> itky <br /> APR 2 0 2012 <br /> B <br /> Attach cumpkte pl m(m the CaWy only)for the sjum tm paPrr not Im tom 91/2 x 11 inches u sue ZONING <br /> SBD-6398 (R. 01/03) <br />