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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 ;' 4 L ti£ <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 t I <br /> Department of Commerce � `'t (l?J1Y) <br /> Sanitary Permit Application State PlanLD D Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(lxm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information � 3 £ <br /> Property Owner's Name /� Parcel# Lot# Block# <br /> �C ')'ll 136, Cl -5 3Z -o3, 6n <br /> Property Owner's Mailing Address Property Location <br /> City,State Zip Code Phone Number <br /> 0JG lc'U R / y U 2_O � (circle mi <br /> TN; R�E <br /> II.Type of Building check all that apply) <br /> ❑ 1 ort Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> CSt'V) (/s�. ` A 9[JZ <br /> ❑Public/Commemial-Describe Use <br /> ElState Owned-Desenbe Use ❑City_❑village;xx,,,.ownship of e f �✓ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. &New System ys L1 Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> OOF <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 /> KNon-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 ❑Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter fillieachingClumber ❑Drip Line ❑Gravel-less Pipe ❑Other(ezpl ) <br /> V.Dis ersal/freatment Area Information: — _T — O'f4 ; K. -q 7 ..- e- s,S <br /> Design Flow(gpd) Design Soil Ap lica[ion Md f) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Sou L/ I70(p 7aS 1 9S.os 9><.811� <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 /> TaNn Tanks <br /> Septic Holding Tank j�OD Q0D 5 <br /> Aerobic Ttesumnt Unit (J V <br /> ZgSc/ ion <br /> Dosing Chamber <br /> I.Responsibility Statement- 1,the undersigned,assume responsibility for instal of the POWTS shown on the attached plans. <br /> PI tier's Name(Print) Plumber's Signature Number Business Phone Number <br /> uc ay�/ �s Zz1, - y7L-LYZI <br /> PI ber's Address(Street,City,State,Zip e) <br /> � b55 - " J-71 uc �,` S`ff353 <br /> VI .Coen /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin at Sign o Stamps) <br /> Surcharge Fee) n�too b / <br /> ❑ Owner Given Reason for Denial �S 5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Atpch cemplew plow(to the County only)for am symas on paper not Ins tam 912 x 11 iochn in sift <br /> SBD-6398 (R. 01/03) <br />