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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Ut on-,07)0-- <br /> N- Visconsin <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co <br /> Department of Commerce rl' f[>(608)266-3151 �/ 79� /'N[.J 5 <br /> ' <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(i)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name , Parcel# Lot# Block# <br /> aCa-�r%c'e 0/son a s.�0A6 - ods 30o <br /> Property Owner's Mailing Address Property Location <br /> 3/4, 8S StR lP.4 <br /> -sem'/., Section <br /> City,State Zip Code Phone Number <br /> O07/p e w �- Sys 3 0 cycle ot�el <br /> T Y� N; R�Eo <br /> II.Type of Building(check all that apply) 61 <br /> ,y Subdivision Name CSM Number J <br /> Lry 1 or 2 Family Dwelling-Number of Bedrooms os <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑villageTownship of <br /> &J( <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑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 apply) <br /> Non-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 lin-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 Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(so System Elevation <br /> 300 • it 7s'0 sa 9d• S <br /> VI.Tank Info Capacity in Total Number 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-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /2,cx i/O 41" s 0b6- ells 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ot-77ai0 w y3S pcle6s74r W- .SfIS7- <br /> VI -C P <br /> Cn /De artment Use Only <br /> ove <br /> Apprd ❑Disapproved Sanitary Permit Fee(includes Groundwater IDate Issued Issui A ht Signature amps) <br /> Surcharge Fee) S#�5 T-OP <br /> - , <br /> ❑Owner Given Reason for Denial U 1� � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 z Il Inch"is sin <br /> SBD-6398 (R. 01/03) <br />