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Safety and Buildings Division County <br /> ` W 201 W.Washington Ave.,P.O.Box 7162 3 fn,r n e t-7` <br /> ,sCOns,n Madison,WI 53707-7162 Sanitary Penni Number(lobe filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.Number 9 � <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide � <br /> may be used for secondary purposes Privacy Law,sI 5.04(I)(m) Project Address(if different than mailing address) W, , 1 <br /> 1. Application Information-Please Print All Information J1 FOX <br /> r f IV�I„1 <br /> Property Owner's Name Parcel# Lot# 9 Block# 0 <br /> W044W044m d- t1a i4 (' 0ao4 9d 7,!r---0 S'DD <br /> Property Owner's Mailing Address Property Location <br /> (j_ Hr � Wa. '/., Section 0 <br /> City,State /� Zip Cto�de Phone Number <br /> Fe I'd Uu. 19 r �1 (circle�q��/) <br /> T N; R�b E orV <br /> II.Type of Building(check all that apply) <br /> c�r <br /> riJlOr2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> El ��,^ <br /> ��Public/Commercial-Describe Use ''I\� <br /> ❑State Owned-Describe Use ❑City_❑Village®Township of S�t/Iss W <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> Q New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B, List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal El Permit Revision ❑Change of 11 Permit Transfer to New <br /> Before Expiration Plumber Owner <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 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 ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 5'x`0 . 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 I Tanks <br /> Septic or Holding Tank /L- -1,14R r~ <br /> Aerobic Treatment Unit <br /> Dosing Chamber <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 /> RfG0,04il.,s s-i 7/-1--4 -470 Is- <br /> Plumber's Address(Street,City,State,Zilf Code) <br /> ,41�760 1t — 3s— webs tri w-� �`t�93 <br /> II.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(. cludes Groundwater Date Issued Issuin gen/Signature(No Stamps) <br /> Surcharge Fee) p o fy-� l <br /> ❑ Owner Given Reason for Denial IJV 04 ( l <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than si/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />