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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 13�(In A 411L_ <br /> VviscMadison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co <br /> onsin (608)266-3151 <br /> Delp-artment of Commerce <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,a]5.04(l)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information <br /> Property Omer's Name Parcel 4 Lot# Block 4 <br /> <f A /.% A., (5 q qkl J1 o/t 916 <br /> Property Omer's Mailing Address Property Location QVI-L- �OT <br /> City,State Zip Code Phone Number _'/4, Section /er <br /> 7 e,1,L-4;r- 31 re (circle a_e) <br /> 7 <br /> 11.Type of Building(check all that apply) <br /> X I or2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> El Putahc/Commerclal-Describe Use C�� V. /ic, A /45- <br /> 11 State Owned-Describe Use ElCiLyo_Elviliage Prownshm of Jackoop, <br /> III.Type of Permit: (Check only one box on line A. CompicWhine B if-.ppllcable) <br /> A, New System 11 Replacement System 11 Trmtment/Holdtng Tank Replaccame er Modification to Existing System <br /> B. Permit Renewal Ll Permit Revision El Change of El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Omer <br /> IV.Type of POWTS Systern: (Check all that apply) <br /> XNon-Pressurized In-Ground 0 Mound>24 in,of suitable soil El Mound<24 in.of suitable soil El At-Gradc El Single Pass Sand Filter El <br /> Constructed Weiland 11 Pressurized In-Ground Ll Holding Tank El Peat Filter Ll Aerobic Treatment Unit C1 Recirculating Sand Filter E) <br /> Recirculating Synthetic Media Filter El Leaching Chamber 0 Drip Line Ll Gravel-less Pipe L1 Other(explain) <br /> V.DispersabTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd persal Area Required(at) Dispersal Arm Proposed(sf) System Elevation <br /> 4�rc . 7 7 4 qY a eygl Ff./6 <br /> V1.Tank Info Capacity in Tom] Number Manufacturer Prefab Sim Steel Fiber Plastic <br /> Gallons Gallon, of Units Concrete Constructed Glass <br /> Ne r"a'ai 9 <br /> T w I Tauk�n <br /> ks <br /> Septic or Holding Tank <br /> �m Unit <br /> Aerobic Tivatin t nit <br /> Dosing Chamber I I - <br /> V11.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached Ill <br /> Plumber's Name(Print) lumber's Signature MP/MPRS Number Business Phone Number <br /> A <br /> Rick 11"Pk-1 J P, <br /> Plumber's Address(Street,City,Scsi Zip Code) <br /> of 7 7 010 Alw y <br /> VIII.CountylDepartment Use Old. <br /> 1)(Approved El Disapproved Sanitary Permit Fee(includes Groundwater ignature tamps) <br /> Surcharge Fee) <br /> !or Denial <br /> El Omer Given Rawson 1. If ,)50 <br /> [X.Conditions of ApprovaVReasons for Disapproval <br /> Attach complete plam(to the County only)for the system on paper not[us tium 81/2 a I I bathes in si,re <br /> SBD-6398 (R. 01/03) <br /> I I in I <br />