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Safety and Buildings Division -Tf— <br /> m 201 W Washington A c.,PO Box 'i6-' Qurgdy{����� �I <br /> ` I Madison,W1 53701-7162 �an!tar P.tn it Number to be filled m ny Co <br /> L isconsin (608)266-3151 <br /> Depy <br /> Department of Commerce <br /> Sanitary Permit Application State Plan 1 D Number — � <br /> Ili accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(I)(m) =Project.AAddress(if differentAaddress)1. Application Information-Please Print All Informationw4r Property Owner's Name Parcel# Lot# <br /> Grp M0 03a-5a-a/ -0(�-760%1a <br /> Property Owner's Mailing Address Property Location 60v,-L COT-. G(4- 3 <br /> V Yrol J-vea./ Grt /.. '/, Section of 6 <br /> City,State Zip Code Phone Number <br /> Forest L/C /Y7/f/, SSOeIS ircleone) <br /> y� �E o&II.Type of Building(check all that apply) T N; R / <br /> Uri or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> /f <br /> ElPublic/Commercial-Describe Use S 142, OS 070 <br /> ❑State Owned-Describe Use ❑City—❑Village PITownship of swrt,S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 4rNew System y El Replacement System ❑Treatment/Holding Tank Replacement Only ❑ 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 /> XNon-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter L <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.Dis (/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sp Dispersal Area Proposed(sf) System Elevation <br /> 300 1 -7 <br /> y�g yid qo. o <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steer Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit <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's Signature MP/MPRS Number Business Phone Number <br /> die/e f/o /��n s 2 � d S-�S/ 7/s- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 76 0 ./ :rs - Weds <✓ u/1- s�/g9� <br /> VIII.Cozen /De artment Use Onl <br /> Approved ❑Disapproved y <br /> Sanitary Permit Fee iincludes Groundwater I Date Issued Issuing A gnature J tamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial I /,4.'I Qj <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 x Il inches in$ire <br /> SBD-6398 (R. 01/03) <br />