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Safety and Buildings Division County <br /> ` � AN 201 W.Washington Ave.,P.O.Box 7162 &Lrn le <br /> Madison, 7f{' <br /> �scons�n on,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 1 O <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide C <br /> may be used for secondary purposes Privacy Law,s15.04(I)(m) Project Address(if different than mailing address) <br /> 1. Application Information—Please Print All Information 906 a <br /> Gong Lk Rd7• <br /> Property Owner's Name Parcel# Lot# Block# <br /> Geri q— Todee Garton 01"— g169'-. 7,10 1 <br /> Property Owner's Mailing Address Property Location 61DV-�- LO 1( I <br /> 0( 9110 f/i/ls✓rew E, <br /> City,State Zip Code Phone Number -A A, Section <br /> /loseViIle /y//fi SS//3 Cis/- 98�t- 8a13d (circle one) <br /> y, <br /> T y0 N; RAE or® <br /> 11.Type of Building(check all that apply) <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use Cs M V, I <br /> 11 State Owned—Describe Use ❑City ❑Village WTownship of 64'07',' <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, 9New S stem <br /> y El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B- ❑Permit Renewal El Permit Revision 11 Change of ❑Permit Transfer m New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stem: Check all that apply) <br /> RrNon—PressurizedIn-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 ersalfrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> -/S-. 1 900 900 '710 <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 Tank 10eO /OOO Sia 4'v <br /> Aerobic Treatment Unit <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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rick //m kir ce�i.eQ rU �J r8s 7/--C'-. 866— cy/s-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77 O h't 3s I-ve6sfr- ws SyS93 <br /> VIII.Count /De artment Use Only <br /> i Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater I Da Issued Issuing gent Signa Stamps) <br /> Surcharge Fee) Jf Cin. <br /> ❑Owner Given Reason for Denial �y JV J 10 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plow(to the County only)for the system on paper not less than 512:I I inches in sice <br /> SBD-6398 (R. 01/03) <br />