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Safety and Buildings Division County <br /> NVIsconsin <br /> m 201 W.Washington Ave.,P.O.Box 7162 Sura P ft <br /> Madison, ) 6-315-7162 Sani Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4" ) S3 <br /> Sanitary Permit Application State Plan 1.13,Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide /C&,h/955< U) <br /> may be used for secondary purposes Privacy Law,s 15.04(1)(m) Project Address(if different than mailing address) Y✓ <br /> I. Application Information-Please Print All Information &ey l (✓2V/lS L k AW" <br /> Property Owner's Name Parcel# Lot-# Block# <br /> �i9v6 /9,v eyson 60.0 - 4335 - 0l3ao <br /> Property Owner's Mailing Address Property Location/�� <br /> /935 it/orfonra /9vao <br /> l�Uv-,- Cor I /5fc. . <br /> City,State�^7 Zip Code Phone Number �'. —��. Section 3S 4 60V� 15 <br /> �{ P Ge l /YIN `S//al (circle gge) 3� <br /> I1.Type of Building(check all that apply) T �(O N; R&L-E c& <br /> 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use L9 qlC!5rn V.3 P,,�3 <br /> ❑State Owned—Describe Use ❑City_❑Villagc KTownship of DAlrla ock <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> EBeforeMpiration <br /> System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. Permitwal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Plumber Owner <br /> S S stem: 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 In-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> `7 SO 9 yso so y lee-&l <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 lO' /�O© <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> (ono (,00 <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP PRS Number Business Phone Number <br /> 1�ft/C l4Co EioS 2 � SBs/ 7iS-�66- �//S'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,- 7760 <br /> M <br /> tment Use Only <br /> sapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin gent Signature(No Stamps) <br /> Surcharge Fee) <br /> wner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ou,uo Cor twt J5L,cL)*T 16r► AssO.1W <br /> DI,Ud0s/orJ /'41 /Lb. (o( SySt��„ ur4fi6� <br /> Attach complete plans(to the County,only)for the system on paper not leas than 81/2 x 11 inches in sisx <br /> SBD-6398 (R. 01/03) <br />