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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 9U Waft <br /> Visconsin Madison,WI 53707-7162 Sanitary"""Pe it Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D. <br /> Number' <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(1)(m) Project <br /> Address(if different than mailing address) <br /> I. Application Information-Please Print All InformationIon <br /> Property Owner's Name Parcel# Lot#� Block# <br /> lU _v ,CJe_ T/vG, ors 36s 61800 <br /> Property Owner's Mailing Address Property Location <br /> Z /r w 3,6 5e V.,ALE-y,, Section <br /> City,State Zip Code Phone Number <br /> �S 66 h69 (circle e) <br /> T�N; RALE or�V <br /> II.Type of Building(check all that apply) <br /> El or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision NamCSM Number <br /> 'e/ <br /> 14 <br /> Public/Commercial-Describe Use &-to Gl9 U. <br /> 13 7 <br /> ❑State Owned-Describe Use rcltY_❑Village'3Township of ee <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System I 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 L' _ 3 <br /> IV.Type of POWTS System: Check all that appi 813E <br /> ❑Non-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 J6 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <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 <br /> Septic or Holding Tank _ y9g w �! <br /> Aerobic Treatment Unit /- <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,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 /> ,«►.au, 1c,Nt f�l+,,,� X12585/ 71 s- UG, QIS7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27760 H 35 WgDsrez WI 54493 <br /> II.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing gent Signature(No Stamps) <br /> Surcharge Fee) ''1 V V. 00 )� <br /> 11 Owner Given Reason for Denial �1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> OCT 2 2003 <br /> Attach complete plans(to the County only)for the system on paper no �{.inegn in size <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />