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Safety and Buildings Division CountyN /L <br /> 261 W.Washington Ave.,P.O. Box 7162 r&e <br /> isconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 55'1 L 3 l <br /> Sanitary Permit Application Sale Plan 1. . Nu/mber <br /> In accord with Comm 83.21_Wis.Adm.Cods,personal information you provide !.`,4 4 v l c(A) C <br /> may be used for secondary,purposes Privacy law,s15.04(IXm) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information nce 776,0 U)ood Z�., / r� <br /> e U 'I <br /> Property Owner's Na /J Parcel i Lot// H Block q <br /> l5cy en 61933ZI63XO o 0l$235 f619L <br /> Property Ow is Ma fling Address Property Location yDd<zo' <br /> 7750 woOdi i%._jV",Section 2 1 <br /> City,Sa Zip Code Phone Number <br /> Uj 5`/�9 716--s66 7672J�eoc e o <br /> T N; R / Eor <br /> H. Type of Building(check all that apply) <br /> 1 Kor 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> I <br /> 11Public/Commercial-Describe Use G'yM 3 12IZ4 <br /> ❑State Owned-Describe Use ❑City_❑Village II'owmhip ofineeAlonj <br /> III.Type of Permit: (Check only one box on line A. Complete Hue B if applicable) <br /> A' ❑ New System � Repsystem ❑ TreemmnUHom mgTark <br /> Replacement Only El Giber Modification in 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.Type of POWTS System: (Check all thatapply) - <br /> tµ Non-Pressurized fin-Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Weiland ❑ Pressurized In-Grund ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Fitter ❑Leaching Chamber ❑Drip Line ❑Gravd-less Pipe ❑Oil=(explain) <br /> V.Dispersalffreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Raw(gpdsb Dispersal Area Required(sf) Dispersal Arm Proposed(sf) System Elevation <br /> y5G 9y00 <br /> VI.Tank Into Capacity in Told Number Manufacturer Prefab Sire Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 756 750 1 ,WCP <br /> Aerobic Tmanrent Unit <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI is Name(Prin n P 's Signa into MPIMPRS NADYAW Business Phone Number <br /> I 7/5—866 -8070 <br /> Plumber's Address(Street ,City,State,Zip C ) <br /> 27ZZo C •h, vs leJP�is�c�4..1� S�fQ4'� <br /> VW.County/Depairtment Use Only <br /> Approved ❑ DisapprovedSamary Permit Fee(includes Groundwater Date Issued Issuin t Sign No Smmps) <br /> El Owner Given Reason for Den al Surcharge Fee) <br /> 3�5 s Q,y11f za( <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> HimML� <br /> AUG 4 2011 <br /> Atmch complete phns(W the Cuawy only)for the syatea ere paper int lea Was inn x 11 inches m IIBURN <br /> Err COUNTY <br /> SBD-6398 (R. 01/03) ZONING <br />