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Safety and Buildings Division Contly/� <br /> Urk 201 W.Washington Ave., P.O.Box 7162 /.�4/' eL <br /> iseonsin Madison,WI 53707-7162 Son Permit Number no be filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> s 85275 <br /> Sanitary Permit Application Sime Plan I.D. Number <br /> In acco.d wim Comm 83.21,Wh.Adm.Code,personal Information you provide 12,M7 & r l 1 <br /> rmy be used for secondary Wrpwes Privacy Law,s15.()4(1)(m) Project Address Cf differcN than mailing address) W <br /> 1. Application Information-Please Print All Infurmatio, <br /> -76 Pcl M Iat N oBlock NP / 2Or a , 4 <br /> C;2 <br /> Property Owner's Ma fling Address Property location Gov't, <br /> City,Sum Zip Cade ft..Number <br /> �� e r G./ 7:7SY930 (circle orc> <br /> IL of Building(check all apply) T N; R <br /> 1.Ty -4,—E 0.0icor 2 Family Dwelling-Number of Bedrooms 17— CSM Number <br /> D Public/Commercial-Describe Use G 2 7 <br /> D ksc <br /> sme oared-Iribe Use �— GCiry GVillage;rownahip of <br /> Gp <br /> III.Type of Permit: (Check only ane box on line A. Complete Bae B if applicable) <br /> AD New System TreatmerWHolding Tank Replacemem Only D Oum Modification to Existing System <br /> B. ❑ Permit Isenewal ❑ Permit Revision <br /> ❑ Change of D Prrmit Tmmkr u New L'ut Previous Permit Number and Date Issued <br /> Delon Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that a 1 ) <br /> D Non-Pressmiaed In-Ground .w Mould > 24 in,m sutuble sog D Mowat < 24 in.of suitable soil D AI-Grade C Sm,;b,Paas Sad Filter <br /> D Conmucied Wdad D Pressurized ln-Gmued D Holding Tank D Peas Filter D Aerobic Traanent Unit D Recirculating SaW Filter <br /> D Retirculating Synthetic Media Filter D Leaching Chamber D Drip Line D Gravel-less Pipe D Other(explain) <br /> V.Dispersal/Treatment Arm Information: <br /> Design Flow(gpd) Deign Soil Application Raw(gpdsf) Dis nal Area Required(sf) Dispersal Area Proposed(so Sys[em Elevation <br /> 3oa 3Qo 300 <br /> VI.Tank Info Capaziry in TaW Number Merwfazmrer Prefab Site Seel Fiber Plastic <br /> Gallons Gallons of Unia Coarm, Comanned Glass <br /> Exiting <br /> Nm T <br /> Sepik or mg a d SO <br /> Aerobia T...Unit <br /> Dwiry Chamber00 56) <br /> Vll. Responsibility Statement- 1,dw undersigned,assume rapansibaily for usuBation or the POWTS shown on the attached plans. <br /> Plumber's Name(Pi.nNt-n Plumber's Signs MP/MPRS Number Business Ph..Number <br /> ,6-A 0//.., a.G -�z 7 Y9-7 X6 <br /> Plumber's Address(S.,City,S.,Zip Code) <br /> VIII.CommyTelartmmat Use Only <br /> Approvd D Diaappmvd Sammy Permit Fee(incl Wes Groundwater Date Issued hetet Signa a Stamps) <br /> Surcharge Fa) <br /> 11Owrter Given Reawn for Denul <br /> IX.Conditions of Approval'Reasons for Disapproval <br /> Am%mmpkte,laa(w de County 0.1y)Nr mrya®an P,r antId thou 21nx H ftc bsize <br /> SBD-6398 (R. 01/03) <br />