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Safety and Buildings Division County <br /> %monsin 201 W.Washington Ave.,0 P.O.Box 7162 $,une i <br /> Madison,9) 6-315–7162 sanitary Permit Number(to be filled m by Co.) <br /> (608)266-31 S I <br /> Department of Commerce 4e5172 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 93.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary,purposes Privacy Law.sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Applications Information—Please Print AN ldormatioa <br /> Bass Lake road <br /> Property Owner's Name Parcel f Lot f Block f <br /> Debra Holter 032-5218-01 5 <br /> 903 <br /> Property 0wncr's Mailing Address Property Location <br /> 7523 Main St. &-60W 4,01A.Section 18 <br /> City,State Zip Code Phone Number <br /> Danbury Wi. 54830 (715)656-3094 T41-N; R-15 E❑orw® <br /> II.Type of Building(check all that apply) Subdivision Name CSM Numba <br /> ®1 in 2 Family Dwelling—Number of Bedromns 2 `720 <br /> ❑Public/Commercial—DaenbeUse_ P .28 #365895 <br /> ❑State Owned—Describe Use_ ❑City❑Village®Township of SWISS <br /> III.Type of Permit: (Cheek only out box on line A. Complete line B if applicable) <br /> A. New System Replacement System Trees anerd/folding Tank Replacement 0 Other Modification to Existing System <br /> Only <br /> g, ❑Permit Renewal ❑Permit Revision ❑Chango of ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration Plumber New Owner <br /> IV.Type of POWTS System: Cheek all that apply) <br /> O Non—Pressurized hWUround ❑ Mount>24 in.of suitable mil ❑ Mound c U in,ofsuirable soil ❑ At-Gtadc ❑ Single Pass Sand Filter ❑ <br /> Comnrcted Wetland ❑ Pressurizcd hW5ra od O Holding Tank ❑Pmt Fitter ❑Aerobic Treatment Unit ❑Recirculating SandFitter ❑ <br /> Recvo dating Synthetic Mathes Filter ®Leaching Clamber ❑Drip Line ❑Gravel-less l? ❑Other(explain) <br /> V. rsaV1'reatmeat Area Information: <br /> Design Flow(oil) Design Soil Applicasian Rats(MmIst) Dispersal Area Required(st) Dispersal Area Proposed(sf) system Elevatme <br /> 300 1 .7 428.6 450 96.00 <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab She Steel Fiber Plastic <br /> Crallore Gallons of Units Concrete Constructed Glass <br /> New I ftsting <br /> Town Too" <br /> a`"""Holding Task 1 1000 1 Wieser Concrete x <br /> Aerobic T¢aaneat Unit <br /> Doming Ono bef 1 600 1 Wieser Concrete x <br /> VII.Responsibility Statement- 1,the odessig*4 wave responsibility for installation of the POWTS zebra an the mashed piam. <br /> Plumber's Name(Prim) Plumber's Signature MP/MPRS Numbs Business Phone Number <br /> Richard O'Hare ��l 225920 715 634-6090 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 14346 W State Rd 77 Hayward,WI 54843 <br /> Coon /De rtment Use Only <br /> Approved ❑Disapproved Satulary a Fee)Fee(includes Groundwater Date Issued Lssuin Signature Stamps) <br /> Surcharge Fee) IDA 9 ' v <br /> ❑Owner Given Reason for o,C0 Daniel W cl /�iC. <br /> Df.Conditions of Approval/Remons for Dimpl ramal <br />