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Safety and Buildings Division County, e-� 1_ <br /> ` M 201 W.Washington Ave.,P.O.Box 7162 (.{ Y h <br /> Is eons�n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce (608)266-3151 f /41 <br /> ,I <br /> Sanitary Permit Application Sate 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,s 15.04(1)(m) Project Address(i(differenl than mailing address) <br /> Application Information-Please PrintAmation //�.,, <br /> eIJC LIQ <br /> Property Owner's Name /', Parcel p Lot# Block# <br /> i >^n �a �Zot' Olio -341 -01 900 <br /> Property Owner's Mailing Address Property Location <br /> City,State6 ., ,�''/., Section t�- <br /> Zip Code Phone Number� r <br /> lJ x �—�(circle o <br /> 11,Type of Bu Ing(check all that apply) i N; RAE ortJ <br /> p I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Numbee, <br /> Public/Commercial-Describe Use Lar i Wwi v23 O/ivp,4 <br /> State Owned -Descnbe Use _ ❑Ciry—❑Village J1Township of L Cp 1,1 <br /> Ill. Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. New System y Y Replacement System ❑ TreatmenUHolding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal - List Previous Permit Number and Date Issued <br /> ❑ Permit Revision ❑ Change of ❑Permit Transfer to New —� <br /> Before Expiration Plumber Owner <br /> IV.T e of POWTS S stem: Check all that a I - <br /> F Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable sail ❑ At-Grade El Single Pass Sand Pilfer" ❑ <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 Dd Other expi( p in) E7-. <br /> a <br /> V.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(SO Dispersal Area Proposed(sl) System Elevation <br /> Sb a7 6V3 <br /> VT.Tank Info Capacity in Total Number Manufacturer Prefab b <br /> Fier <br /> Gallons Gallons of Units Site SteelPlastie <br /> New Existing <br /> Concrete Constructed Glass <br /> TdrlkS Tfl111t6 <br /> Septi Holding TaM X ✓ <br /> Aerobic Treatmem Uun <br /> Dosing Chamber <br /> V71.Responsibility Statement- 1,the ndersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pnno P mber's Sign ore MP/MPRS Number <br /> Business Phone Number <br /> IS <br /> Lot Ir ✓ 22 z2cj 7/ 6— 6 <br /> Plumber's Address(Street,City,Slate,Zi Code) Of <br /> 7XApprovedD <br /> nt Use Only <br /> roved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ignatu No Stamps) <br /> Surcharge Fee) ff A, �Given Reason Cor DentalovaVReasons for Disapproval <br /> Attach eomplcle plains(to the County only)fur the system on paper not less than 81/t x 11 fi-che,In 0. <br /> SBD-6398 (R. 01/03) <br />