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Safety and Buildings Division Countkj <br /> 201 W.Washington Ave.,P.O.Box 7082 t <br /> *sconsin Madison,WI 53707—7082 Sanitary Permit Number(to be filled in b Co,� <br /> De artment of Commerce (608)261-6546 v�? 3� <br /> Sanitary Permit Application State Plan I.D.Number (� 7 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ------� <br /> may be used for secondary purposes Privacy Law,s15.04(1 xm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> -Y-0/ <br /> Property Owner's Name Parcel# Lot# Block# <br /> Property Owner's Mailing Address Property Location <br /> City,State�/ Zip Code Phone Number :�� V., Section 3� <br /> 5J" 00?o alb/ �V 4 J (circle one) <br /> T YO N; R/� lisar W <br /> II.Type of Building(check all that apply) <br /> '1 <br /> YIor2Family Dwelling-Number of Bedrooms �/' (�rsfpy►'� Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> /1,05 saoc& Corjl ,Pry <br /> ❑State Owned-Describe Use ❑City_❑VillageP6ownship of Se-a� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. XNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision 11 Change of El Permit Transfer to New <br /> Inst Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that app 1 <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.DispersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Ates Required(so Dispersal Area Proposed(so 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 Existing <br /> Tanks I Tanks <br /> r Holding Tank ;�aV <br /> Aerobic Treatment Unit <br /> knfqfi!mhX <br /> VIL Responsibility Statement-I,the undersigned,assume res ponsibili f installation of the POWTS shown on the attached plans. <br /> Pl ber's Name(Print) Plumber' i MP/MPRS Number Business Phone Number <br /> �' <br /> ;Z211177 /5 Xe(5 27 S el` <br /> Plum 's Address treet,City,State,Zip ) <br /> VIII.County/Department Use Only <br /> pproved ❑Disapproved "�Y Penm't F (includes Groundwater Date Issued Issuing Agent Signature(No S ) <br /> SurchargeFee)IJ <br /> ❑Owner Given Reason for Denial <br /> IX Conditions of Approval/Reasons for Disapproval <br /> Attach complete plane(to the County only)for the system on paper mot has than 81a z 11 Inches In size <br /> SBD-6398 (R. 08/02) <br />