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Safety and Buildings Division County <br /> ` <br /> 201 W. Washington Ave., P.O. Box 7162 w <br /> iseonsin Madison,WI 53707-7162 Sanitary Permit�Number(m be filled in by Ca.) <br /> Department of Commerce (W8)266-3151 Ze;7� <br /> Sanitary Permit Application Sum Fism I.D. Number <br /> In accord with Comm 83.21,Wis.Adm.Cade,personal information you provide / 4&(i I <br /> may be used for secondary prsmmea Privacy taw,s15.04(1)(m) ProJect Address(if different than mailing address) <br /> 1. Application Information-Please Print All Infornnatioa � 1 ^DU✓1 �313Ct� � 8 Dr, <br /> P. 'YOwrsei s Name Parcel# Las N 9 '5 B1. M <br /> / N <br /> Property Owner's Ma iling Address Property Landon <br /> O <br /> City,Stam Zip Code Phone Number ts• 4.Secu0m <br /> ;ser w 54oaa /a5-�s9� 7q (circle ane) <br /> IL Type of Building(check all that apply) �7 T N; n o e q!Y C <br /> XI or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name// CSM Number <br /> ❑Pubik/Commercial-Describe Use e,Na4 <br /> ❑Stam Owned-Describe Use OCiry_�VBlage�YowmMp of <br /> G G <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y placemem System ❑TrcatmcrWHolding TaNc Replacemem ONy ❑ Otlur Modification in Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Clunge of ❑Permit Transfer in New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> D Non-Pressurtrcd N-Ground I$1Mausd > 24 in.of suitable sod ❑ Mausd < 24m.m suitable soil ❑ A,-GM, ❑ Single Pass SaM Filter <br /> ❑ Comlrueted Welland ❑ Pressuriaini in-Ground ❑ Holding Tank D Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Saint Filter <br /> ❑ Recirculating Synthetic Media Filter ❑Leaminig Chamber ❑Drip Lt. ❑Gravel-las Pipe ❑Other(explain) <br /> V.Dis rsal/Treatmeat Area Information: <br /> Dain Flow(gpd) Design Soil Application Ram((( so Dispersal Ara gemmed(s0 Dispersal Arm Proposed(s0 System Elevmion <br /> 00 3av 3� U ,6 <br /> VI.Tank Info Capacity in Total Number Ma nufaeums Prefab St. Steel Fiber Plastic <br /> Gallons Gat of Units Conerek Constructed Glaze <br /> New Faimisg <br /> Tanta Ta,la <br /> Septic or Holdi,y Tank S� 1 17-5-0 <br /> Aembie Treatment Unit <br /> Dosiry CMrrber 00 sed() <br /> VII. Responsibility Statement- 1,the under igned,assume responsibility for transitions of the POWTS shown on the inhalmd plans. <br /> Plearka t,Name(Priv it / number's Signs one MP/MPRS Number Business PMrc Number <br /> Plumber'.Address(Sue[ ,City,Stam,Zip Cade) <br /> f <br /> vita Count /De artment Use only <br /> Approved ❑ Disappuvel Sanitary Permit Fee(ineluda G..Wwata Date Issued Imui t Signs o Sumps) <br /> Surtharge Fm) 0 3Da� f <br /> ❑ Owner Givrn Reason fou Denial '(l JiLy �i <br /> IX.Conditions of Approval/Reassures for Disapproval <br /> Attacks mmylme Plass tm the Couaty Only)in,rise"an an Pacer cot leas Nal RA x 11 luckiest ti doe <br /> SBD-6398 (R. 01/03) <br />