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Safety and Buildings Division —i Conry <br /> 201 W. Washington Ave P.O.Box Qy�ge7T- <br /> ��������� Madison,Wl 53707-7162 Sanitary Pemtil Number(to be of ed it by to <br /> (608)266-3151 <br /> Department of Commerce f72 4b —� <br /> Sanitary Permit Application State P'an"' N°tuber - <br /> In accord with Comm 83 21,Wis.Adm-Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(1)(n) Proja:t Address(ifdifferenl than mailing addto <br /> I. Application Information-Please Print All Information 6 d( F3 U. e'f- C '- <br /> Property Owner's Name Parcel# Lot# Block# <br /> -- <br /> Property Owner's Mailing Address Progeny Location <br /> V*-• Co S+(a <br /> Jr-'06I�arkSh:rt CT <br /> City,State Zip Code Phone Number —�A, —'/-, Section /0 <br /> Lora rs v.WC f<y ly0o(f(f Ufa (circle one) <br /> II.Type of Building(check all that apply) T N; R /b E orS <br /> 2r1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use ,Cj r g P, /e I <br /> ❑State Owned-Describe Use ❑City_OVillage QTownship of Opo/dab( <br /> III. EPcnnitRenewal <br /> : (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> $Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B• wal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> n Plumber Ownerrrl��nnnV...'''T S stem: Check all that apply) <br /> ----� <br /> sp IVon-Pressurized In-Ground ❑ Mound>24 in.of suitable sod ❑ Mound<24 m.ofsuitable soil ❑ At-Grade ❑ Single Pass Sand Filter L—� <br /> Constructed Welland ❑ 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, <br /> Dis erssI/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsO Dispersal.Area Required(sl) Dispersal Area Proposed(st) System Elevation <br /> ql. _d .7 6. 64� 9y�3 <br /> ITT 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 Tanks <br /> Septic or Holding Tank 1000 <br /> ioao <br /> Aerobic Treatment Unit <br /> Dosing Chamber 6eC Z.0 <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/hIPRS Number Business Phone Number <br /> 1?,et f/o " * - /1 � A SSS( 7/5- X66-y/s7 <br /> Plumber's Address(Street,City,Slate,Zip Code) <br /> d 7760 f/w 3s <br /> we 6 "I"' wr s�sy3 <br /> VIII.Court /De art----Ose Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee lincludes Groundwater I Date Issued Issuing A t ignature amps) <br /> Surcharge Fee) fy y, <br /> 11 Owner Given Reason for Denial 4r' ��(/ <br /> IX.Canditlons of ApprovaVReasons for Disapproval sr <br /> Attach complete plans(to the County only)for the system on paper not Its Zhao 81/2 z 11 inches io sire <br /> SBD-6398 (R. 01/03) <br />