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Safety and Buildings Divispon County <br /> 201 W.Washington Ave.,P.O.Box 7162 Bk r- <br /> ` ,�� p7_ <br /> onsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co <br /> of Commerce ,I <br /> onsin 266-3151 <br /> Department 1 V <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy taw,sI5.04(I)(m) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Information 75�� /iQ�eOf'1 Lry <br /> Property Owner's Name Parcel# Lot# Block# <br /> rep, O/soH ado 9/70 0 tsar <br /> Property Owner's Mailing Address ®® Property Location <br /> 6176-57, "GkfM A4 r„ �6 01"ICity,State Zip Code Phone Number 1/.1 Section <br /> WoodbKr M Al, Ssrdr esu- 73`- TN; R (circle one) <br /> � <br /> 11.Type of Building(check all that apply) 1(a-E or® <br /> a' <br /> �l or 2 Family Dwelling-Number of Bedrooms Subdivision Name 44Yr S CSM Number <br /> gQ �, <br /> 13Public/Commercial-Describe Use 1-r t 0toLo La G7 <br /> ❑State Owned-Describe Use ❑City_❑Village Township of&4*1x s,0 <br /> i1f.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System y ep y 9 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 qll(d <br /> 9 <br /> 17 <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of st itable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ At robic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less ipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(so 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 7SO 7S0 <br /> Aerobic Treatment Unit <br /> Dosing Chamber S&V S+OQ <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 /> /CIG/< h!o /C;n S 1,?,4acex- 7iS- 866—ZIis-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,47760 w 3.f klo65Ae.- W.. -s` ,5?1 <br /> VIII Coun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Ground ater Date Issued Issuing tgnatur tamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on page not less than gl/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />