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Safety and Buildings Division County�? <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Vct r/1 e/ <br /> lVisconsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 113 <br /> Plan I.D.Number <br /> Sanitary Permit Application State / 9J <br /> In accord with Comm 812 1,Wis.Adm.Code,personal information you provide fb1� 117540 <br /> may be used for secondary purposes Privacy Law,sI5.64(1)(m) Project Address(if different than mailing address) U) <br /> I. Application Information—Please Print AB Information : �57 69 /�)a I Dr. <br /> Property Owner's Name J Parcel# 4 I ILot# Block# <br /> rm Gases 63d 5335 67300 <br /> Property Owner's Mailing Address Property Location <br /> 760�/ �ias eel- �ov �. (o r (o <br /> City,State Zip Code Phone Number ��•. —V,. Section 3..r <br /> pha r L�� �4>�30 (circle e) <br /> II.Type of Building T �/I N; It�6 E o� <br /> yp g(check all that apply) <br /> Al or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> ❑State Owned—Describe Use ❑City_❑villageXTownshipof wfls <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> `k' ❑New System y , Replacement System ❑Treatment/Holding Tank Replacement Only 11 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.TM of POWTS System: Check all that apply) <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]n-Ground _1�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.Dia ersal/Treatin nt Area Information: <br /> Desi gt4Infocapacity <br /> esign Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> VI.TCapacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constmeted Glass <br /> ew Existinganks TanksSeptic oeo .�� 2 AerobicDosing <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 /> i/ /cf,, 7/S- g6G- ell <br /> Plumber's Address(Street,City,State,Zip Code) <br /> at 7760 n'H 3r webs�t- —Sof 893 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin A t Signa o Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial 3wv f I O <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> I, <br /> 20 <br /> Attach complete plow(to the County only)for the system on not le ,.th,�q a{/�,a�l jndrtallA e <br /> BUttlr 11 IfVV <br /> SBD-6398 (R. 01/03) <br /> ZONING <br />