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v t,UIVIHUi ER/SCANNED <br /> IAff.sconsin <br /> Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Qa vn-e <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <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(1)(m) Project Address(if different than mailing address) (1 ) <br /> I. Application Information-Please Print All Information //-- a[. <br /> K n <br /> Ki I�GAt^t <br /> Property Owner's Name Parcel# Lot#1 Block# <br /> �ratiar-d �c�rb _ a <br /> Property Owner's Mailing Address Property Location <br /> d46se k i( 'arc Rd• G'ov't, <br /> City,State %., V., Section /3 <br /> Y Zip Code Phone Number <br /> 04tihotr y w Sy 31.3 7/S -.1rcy- 7y9/ R/ circleoe) <br /> E orW <br /> II.Type of Bmlding(check all that apply) T 90 N; <br /> 9 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use v P.3a 3 <br /> ❑State Owned-Describe Use ❑City_❑Village kTTownship of t)4w_1ZA0rL <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 ❑Other Modification to Existing System <br /> B. El Permit Renewal El Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> t, <br /> ITV.Type of POWTS System: Check all that apply) <br /> 4124Non-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.Dis <br /> Deersal/Treatment Area Information: <br /> sign Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 60� <br /> . 7 no il 9S.S/ower 9vPpef <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site S[e Fiber Plastic <br /> Gallons Gallons of Units Concrete Constmcted Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit ^� <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,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 /> /?icle— f10 k S /t"„y( u 111"Olt lir 5`66-5'/s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77(00 //&. v 35- wC6.s)4rr A:/r— -s�9'93 <br /> county/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fe (includes Groundwater Date Issued Issuing gent Signature(No Stamps) <br /> ❑Owner Given Reason for Denial Surcharge Fee) <br /> IX.Conditions of Approval/Reasons for Disapproval _7 <br /> (3URNZ0 INGUNTY <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />