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Sd <br /> Nvisconsin <br /> Safety and Buildings Division County <br /> 42.J201 W.Washington Ave.,P.O.Box 7162 Madison,WI 53707—7162 Sanitary Permit Number(to be fillzd in <br /> Department of Commerce (608)266-3151 ,r 3E 32g Jul <br /> Sanitary Permit Application State Plan I.D.N4um2ber_ <br /> In accord with Comm 83.2 1.Wis.Adm Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1 xm) <br /> 1. Application Information-Please Print All Information <br /> V Z$_ 2to_ o Z, <br /> Property Owner's Name Parcel# Lot k Block n <br /> iek_ pr-nz <br /> Property Owner's Mailing Address Property Location _-- -. --- <br /> 13-7I G�+ �� t-- Pel. Crou`� Lot -5L— <br /> City,State�r. - Zip Code Phone Number t/a Section .24 <br /> 7 <br /> &35 $ (0 (circle <br /> T N b N; RLE of W <br /> Subdivision Name CSM Number <br /> ❑City ❑Village Township of :>CjDftl <br /> ILL Type of Permit: (Check only one box on line A Complete line B if applicable) <br /> ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing Svsmu <br /> 8, ._; Penna mi <br /> Renewal j ❑ Yert Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Dal•Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System: (Check all that apply) <br /> J Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ AI-Grade ❑ Single Pass Sand Filter Coactrucicd <br /> Wetland ❑ Pressurized In-Ground XHolding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ Recirculating Synthetic Media <br /> Filter J Leaching Chamber ❑Drip Line ❑Gravel-less Pipe El Other(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sI) Dispersal Area Proposed(sf) System Elevation <br /> 150 i.-. -✓1 1.\0 <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel er j Plastic <br /> ,. Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing j <br /> _ Tutks Tanks <br /> Dosing Chamber - <br /> I <br /> VII. Responsibility Statement- I,the undersigned,asaume responsibility for"don 9f the PONYTS shown on the attached plans. <br /> Plumber's Name(Priv 1 Plumber's Signature RS Num �a/ k7967 Business Phone Number <br /> M$K SEr i ie & 6WAVAT10 C f `1 c0 <br /> Plu f . ode) <br /> 5 trtw� <br /> VIII. County epartmcut Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signature Stamps) <br /> Approvzd ❑ Disapproved Surcharge Fee) A <br /> ❑ Owner Given Reason for Denial ` tJ. J 41)(- 0 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> V <br /> Attach complete plana(b the County only)for the system on paper not leu than BINS s 11 Inches In ala i <br />