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Safely and Buildings Division County <br /> ` 201 W.Washington Ave.,11.0.Box 7162 <br /> iseonsin Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3 15 1 <br /> Sanitary Permit Application state PlanI.D Number <br /> In accord with Comm 83.21,Wis.Adm Code,personal information you provide W <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) O <br /> n I <br /> 1. Application Information-Plcasc Print All Information <br /> Property Owner's Name Parcel# Lot# Block# <br /> roperty Owner's Mailing Address Property Location <br /> V62 0 / / <br /> City,State _�, _Y., Section <br /> Y Zip Code Phone Number <br /> (� >eiiij : gy-2 97 circle one) <br /> N; E or <br /> 11..Type of Q ' ing(check all that apply) R 0 <br /> � I S <br /> r�or 2 Family Dwelling-Number of Bedrooms S x - -- CSM Number <br /> ❑Public/Commercial-Describe Use Z <br /> 11 State Owned-Describe Use ❑City_❑villagFewnship of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, <br /> ❑ New System eplacemenl System ❑ 'IYeatmenUHolding'Pank Replacement Only Ll 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 /> Oxon-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.orsuitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Welland ❑Pressurized In-Ground ❑ Ifolding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filler ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V. Dis ersalffreatment Area Information: <br /> Design Flow( Design Soil Application Rate )ersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> SO �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 /> Tanks'7 Tanks <br /> Septic or Holding Tank QQv �ra� <br /> Aerobic Trea nwnt Unit (/ <br /> Dosing Chamber /11 <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the ntlached plans. <br /> Plumber's Name(P in Plumber's Signature MP/MPR$Number Business Phone Number <br /> 40 <br /> umber's Address(Street,City,State,Zip Code) <br /> j/ //^�•,/ Q✓ <br /> 1.Count /De artment Use Only- <br /> roved ❑ Disapproved Sanitary Permit Fee,,,(((includes Groundwater Date Issued Issuin gent Signature(No Stamps) <br /> Surcharge Pee) ^)�' ,�,rsl 1I" s,u, <br /> El Owner Given Reason for Denial <br /> �{ 00 J 4 <br /> IX.Conditions of ApprovaVRcasons for Disapproval <br /> Attach ctnnplete plans(to the Co,oty only)nor the system on paper not less than 81/2 x 1I inches in eiu <br /> SBD-6398 (R. 01/03) <br />