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ON COMPUTER/SCANNED <br /> Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 ./Fur n el� <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 qg 3 32 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sI5.04(Ixm) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Information o( �efyD 'ti• Y2!/ew �r�'e� /�p4 <br /> Property Owner's Name Parcel# Lot# Block# - <br /> Gra.rt siy +h od0- 9307 oSOOO <br /> Property Owner's Mailing Address Pro I Location <br /> Sl' iVW S(c� -7City,State Zip Code Phone Number �A• Section <br /> AnO�O✓Cr n! S$304 6/}- 716 -7979 T yoN (circle one) <br /> 11.Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> [AIOr2 Family Dwelling-Number of Bedrooms Cs r <br /> i <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village 8'fownship of G'bIK/a evc;0 <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of 70mer it Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber <br /> IV.Tvoe 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(so Dispersal Area Proposed(sf) System Elevation <br /> Ssa 7 G'13 G ti� s,4' O <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 Tanks <br /> Septic or Holding Tank /9101/ /919191 �_ Jr/CA .v. X <br /> Aerobic Treatment Unit <br /> Dosing Chamber <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/MPRS Number Business Phone Number <br /> ..pe /5� k.-3 /2,,,..,91 �d.S-8S/ 7/s= 296 6 -4!s 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> oA7760 /> 3S we6s,4. w-E <br /> VIII.Coun /De artment Use only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issui gent Sign o Stamps) <br /> Approved ❑ Disapproved Surcharge Fee) C7� <br /> ❑Owner Given Reason for Denial 2Jv AP �3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not has than$112 s 11 Inches in size <br /> SBD-6398 (R. 01/03) <br />