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ke- <br /> ` Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 N <br /> Vscons�n Madison W[ 53707-7162 Sanitary Permit Number(to be tlled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> 4-7 <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,sl5 04(I)(m) Project Address(if different than mailing address) ( �) <br /> I. Application Information-Please Print All Information <br /> Pro pe Owner's Name Parcel# Lot# / Block 4 <br /> � 2i,J o2 <br /> Property Owner's Mailing Address n,r� Property Location P / <br /> /io e b=C/�, <br /> Ci State _'A, '/., Section 27 <br /> tY. // ' 1 Ph/onppe Number D- KIpm' �0 I tee <br /> yt�l <br /> bfAr W U' 09 '�ZZ3� u_rccT�e on R <br /> II.Type of Building(ch all that apply) T N; R _E <br /> --'�• <br /> �or 2 Family Dwelling-Number of Bedrooms CSM Number? <br /> ❑Public/Commercial-Describe Use -- 7 <br /> El Store Owned-Describe Use r ❑City_❑villa ship of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �1119w System y El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that a I <br /> n-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 ersal/Reatment Area Information: <br /> Design Flow(gpd) Design Soil App1i�n Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(at) System Elevation <br /> 500991 --- <br /> VI. <br /> Tank Info Capacity in Total I Number I 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 -.- <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume res nsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pri [) Plumber's Signature MP/MPRS Number Business Phone Number <br /> �a <br /> tum is Addms ( reet,City,State,Zip Code) <br /> VI .County/Department Use On] <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin ge ignatu tamps) <br /> Surcharge Fee) n <I <br /> 11 <br /> Owner Given Reason for Denial /C <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> uoTC: Sall Conetikii, .§ aye uNust).u, 517E APe6LU r Be Aa *)CI dT &AC <br /> 061ov'r WuA-c y -r ubo-P K6• 5)7-6 SGoI°6s Taw4&O Cor&14x.0{' <br /> /-1006 A0 C*- vu. <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x Il inches in size <br /> SBD-6398 (R. 01/03) <br />