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Safety and Buildings Division County ((�� <br /> 201 W.Washington Ave.,P.O.Box 7162 /,� / w e,- <br /> VVisconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-31sT 7$5g1 <br /> Sanitary Permit Application State Pin I.D.Number <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide )) 6)I(RO <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information / <br /> s <br /> Property Owner's Name Parcel# Lot#3 Block# <br /> dim �r iso.J 3 - a 0 Lcao <br /> PropertypOwner's Mailing Address Property Location <br /> U 6 V /S.'� Nrtl 1, N6 ', Section <br /> City,Stale y[, Zip Code Phone Number <br /> I7/ 6 7 T!/N; R �6 ir oeffi <br /> It.Type of Building(check all that apply) <br /> q rson Name CSM Number <br /> 3a 1 or 2 Family Dwelling-Number of Bedrooms 3 <br /> ❑Public/Commercial-Describe Use V '?/ �" <br /> ❑State Owned-Describe Use ❑City_❑Village Iq r ownship of <br /> XeV ass <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. %New System ❑ Replacement System ❑Tremment/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 <br /> IV.Type of POWTS Sys rw. Check all that a 1 <br /> ❑Non-Pressurized In-Ground KMound>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 Rale(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) 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 I Existing <br /> Tanks Tanks <br /> Septic or HoMmir4aak J6,% _ /Doo <br /> Aerobic Treatment Unit <br /> Dosing Chamber -t-- <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name( rut) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) ry <br /> VIII.Coun /De artment Use Oat <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signam Stamps) <br /> Surcharge Fee) N <br /> L1 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not Ices than 812 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />