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Safety and Buildings Division County <br /> Asconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 42 5a <br /> 7 <br /> � g <br /> I <br /> Sanitary Permit Application State Plan I.D.Nymber <br /> In accord with Comm 83.21,Wis.Adm.Cody personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(l)(m) Project Address(If diiiffferent thane nut6hng address) <br /> I. Application Information-Please Print AB Information &/I- <br /> Property Property Owner's Name Parcel# Lot# 7 Block# <br /> e C mm�r�e a- a - goo <br /> Property Owner's Mailing Address Property Location <br /> //a'7 -Zo ef- e� <br /> City,State Zip Cade Phone Number �-" Y., f!Y., section <br /> /Of X80 7�s)3v5 ds�vcircle me) <br /> H.Type of Building(ebeck all that apply) T�d N; RAJ . <br /> jbr or 2 Family Dwelling-Number of Bedrooms Subdivision Nam4 ))CSM Number <br /> Public/Commetcial-Describe Use, r Qt-ler) <br /> 0 Stunk Owned-Describe Use ❑CitY�] dVgeg,[fownship of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 13 New system ❑Replacement system ❑Treatment(Holding Tank Replacement <br /> Only 13 Other Modiseapon 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 System: Check an that apply) <br /> Non-Preeauriad In-Ground ❑Mound>24 m.of suitabk soil 13Mound<24 m of snitabiesoil 13 At-'wade ❑Single Pass Sand Filter <br /> nutted wetland 13 Pressurised in-Grmmd 13 Holding Tank [3 Pat Filter ❑Aerobic Treatment Unit ❑Recirculating Sad Filter ❑ <br /> RecirertLdn S dietic Media Filter ❑Lcaebnng Chamber 13 Drip Line 0 Gavel-kas Pipe ❑other(explain) <br /> V. rsal/Treatment Area Idormatior <br /> Design Flow(gpd) Design soil Application Rate(gpdso Dispersal Area Required(sin) Dispersal Area Proposed(lit) system Elevation <br /> VL Tank Ido Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Exbtiog <br /> Tads Tnk <br /> Septic or[kWmg Took p001600 I <br /> Amble Treatment Una <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the wa4w1ljWqi1,yeame a"nity for installation of the PowTs shown on the atgebed plans. <br /> Plumber's Name(Print) P 's i MP/MPRS Number Business Phone Number <br /> John Solofra #223779 715-376-2278 <br /> Plumber's Address(Street,City,State,Zip <br /> PO Box 161; Gordon, WZ 54838 <br /> VIII.Cour rtment Use only <br /> ❑Approved 1 ❑Disapproved Sanitary Permit Fee(includes Groundwater Ila Issued Issuing Agent Sigoenne(No Stamps) <br /> Surcharge Fee) <br /> El Owner Given Reason for Devial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attaeb a mpkie pian,(to the Cosner osry)rw the entero os paper sot less toot 8112:11 laebes In sin <br /> SBD-6398 (R. 01/03) <br />