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Safely and Buildings Division County <br /> ` 206 W. Washington Ave.,P.O. [lox 7162 fin/ e <br /> �S/��/�J�lh Madisoo,Wl 53707-7162 Sanitary PcrmitNunilacr(to belilledInIn <br /> Department of aCommerce (608)266-3151 <br /> Sanitary Permit Application Stale Plan l.DD.`Number <br /> Inlaccord with Comm 83 21,Wis.Adm,Code,personal iulbrmution you provide 7✓7850 <br /> may be used for secondary purposes Privacy lam,sLiA4(I)(m) Project Address(if dills enl than In <br /> address) <br /> 1. Application Inform(lion-Please Print All Information �� 3oz8 <br /> Property Owner's Name farce(# O I.ot 8 Block# <br /> property Owner's MM ing Address Property Location.0�_L G L <br /> oCO�7 �/j <br /> ` r 4 — '/,. �/,, Section /-� <br /> C�itty,State Zip Ctklc Phone Number —A <br /> c / circle one) <br /> lin� <br /> 11.Type of Middling(check all that apply) 3 - <br /> Subdivision Name CSM Number <br /> �or2 Family Dwelling-Number of Bedrooms' <br /> ❑Public/Commercial-Describe Usc <br /> ❑Slate Owned-Describe Use OCily_Ovillage ''nwnship of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement System ❑ 'I calmcnt/I lolding'1'ank Replacement Only ❑ Other Modification In lisisling System <br /> B. O Permit Renewal ❑ Permit Revision ❑ Change ul ❑I'ermit'I'mns'Icr In Ncw List Previous Permit Number and Date Issued <br /> Belpre Expiration ['lumber Owner <br /> IV-'ry a of POW7'S system: Check all that apply) <br /> _ <br /> O Non-Pressurized In-Ground K Mound>24 in,ol'suiulble soil ❑ Mound<24 inof suitable soil ❑ At-Grade ❑ Single['ass Sand Fiber ❑ <br /> Constructed Welland O Pressurized Iu-Ground n I Inlding'I':mk ❑fent Piller U Acrobic'I'rcaunenl Unit ❑Recirculating Solid Filter ❑ <br /> Recirculating Synthetic Media filler U Leaching Chamber U Drip Line U Gravel-less Pipe U Other(explain) <br /> I <br /> solfFrcatment Area Infurmation: <br /> w(gpd) Design Soil Application Rate(gpdso Dispersal Aren 12equired(sl) Dispersal Area Proposed(so System P.levalion <br /> zz�o '15-- Sa s'� 7. 3 <br /> Info Capacity In Total Number Manulhcurer Prefab Site Sect Fibcr Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> 'Tanks 'ranks <br /> Iding7enk Q0:1 z <br /> atnncnt Unit V !/V - <br /> Dosing Chamber l <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for inslallatiun of the POW'TS shown on the attached plans. <br /> Plumber's'Namc(Print) Plumber's SignatuMP/M111'RS Number Business Phone Number <br /> 4d M Gva. re z Z7 <br /> Plumber's Address Slreel,City,State,Zip Code) <br /> Ile— <br /> VIII.Countv/Dc artment Use Onh <br /> Approved ❑ Disapproved San iluq 1:nn t i'a(includes G(ryujndwater Date/is`suedy� Issuin enl Signauu• Stamps') <br /> Surchargee Pec) 350 i i1 Ma t <br /> ❑Owner Given Reason lie Ucnial _ <br /> IX.Conditions of Appruval/Reasons for Disapproval <br /> Attach campkte plans(In the Cl unp only)far the oo.n nn paper not less deur 81/2 111 inches in size <br /> SBD-6398 (R. 01/03) <br />