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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 U r e <br /> Visconsin Madison,Wl 53707-7162 Sanitary Pe mit Number(to be filled in by Co.) / t <br /> (608)266-3151 1p O <br /> De artment of Commerce !!O <br /> Sanitary Permit Application state Plan I.D.Nam <br /> ber <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)(m) Project Address(if different than mailing address) <br /> 1. ApplicationInformation—Please Print All Information 3 �lc� S-Ll> A-.3�h <br /> Property Owner's Name / Parcel# VJ Lot is I Block#J <br /> 03 Z 5-32-3 OZZ©O <br /> Property 0 er's Mailing Address Property Location <br /> 1 )I <br /> 1 E Y., I '/., Section <br /> City,State 1L p Zip Code Phone Number <br /> — <br /> Nrx �U( W t J-4 ?j �7 9'5 67 cucleo <br /> �11a.Type of Building(check all that apply) Z T y N; RE or <br /> bI or 2 Family Dwelling—Number of Bedrooms / Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use 'IOD,- <br /> 11 State Owned—Describe Use ❑City_❑Village JiTrownship of (.,t91 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y El Replacement System ❑Treatment/Holding Tank Replacement Only L1 Other Modification to Existing System <br /> D. ❑ Permi[Renewal El Permit Revision C1 Change of ❑Permit Transfer o New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type ofPOWTS System: Check all that apply) <br /> 'K 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-las Pipe ❑Other(explain) <br /> V.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdso Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> ysb 6Y3 1 6' y8 9p0 <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 Ta: <br /> Aerobic Treatment Un it <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) Plu is Signature MP/MPRS Number Business Phone Number <br /> chard kt'fJ 1 ZZS85/ 7/5- <br /> - q! 57 <br /> Plumber's Address(Street.City,Sure,Zip Code) <br /> 27720 11WY 3 We� Ar <br /> V�I/II.Coun /De ar ment Use Old <br /> LA.Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui t Signal o Sumps) <br /> ❑ Surcharge Fee) /J O��`�{�Owner Given Reason for Denial r� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attuh complete plum(to the County only)for the system on paper not has than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />