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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,W1 53707-7162 Sanitary Permit No ber(to be filled in by Co.) <br /> Visconsin <br /> (608)266-3151 '�h''11�S <br /> Department of Commerce Zg <br /> Sanitary Permit Application State Plan I.D.Nor iber <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide IJ4- <br /> may be used for secondary purposes Privacy taw,s 15.04(1)(m) Project Address(if liffeTent than mailing address) <br /> 1. Application Information-Please Print All Informatio ) <br /> Property Owner's Name - / Parcel# t Lot# Bleek N <br /> �TEReiyl �1>tJEXJ(J 0� 9/cs - �_ �bo La7 <o <br /> Property Owner's Mailing Address Property Location ( l 1 <br /> 907/_/ /ldi�W(/W/ SPD � / w <br /> City,State Zip Code Phone Number — /., Section <br /> eSA NISI©/� 5S`J7171V---z96-_7 2-1 C� T y� N; R/ (cEcleyt�) <br /> 11.Type of Building(check all that apply) } M WJ <br /> 0)or 2 Family Dwelling-Number of Bedrooms J Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use �S iZ k�7}— )2E-5 <br /> ❑State Owned-Describe Use ❑City_❑village Township of <br /> 111.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A' g'New System ❑ R Replacement System ep y ❑T¢atmenUHolding Tank Replacement Only ❑Other Modificati n to Existing System <br /> B. ❑Permit Renewal 11Permit Revision 11Change 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 /> XNon-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑Sin Ie Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recircul ing Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pie ❑Other(explain) <br /> V.Dia ersaltTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsi) Dispersal Arca Required(sf) Dispersal Area Proposed(so 5 tem Elevation <br /> - 7 6<13 Z,56) 9& .5 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel er Plastic <br /> Gallons Gallons of Units Concrete Constru Fibed Glass <br /> New Exiaring ' 1 ���� <br /> Septic or Holding Tank /OQ /�p �/ZQ DurTs <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attacl ed plans. <br /> Plumber's Name(Print) Plumb Signature MP/MPRS Number Rusin ss Phone Number <br /> Ag'Arw-4D ^fT � 22-ca-e—70 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1471 -3 <S. •QD 35` 4AX'_,6u-AY- t3i - S-Y8 30 <br /> VII Court /De artment Use Onl <br /> Approved 11 Disapproved Sanitary Permit Fee(includes P.reandwater Date Issued Issui t Signa o Stamps) <br /> Surcharge Fee) d/ �50� ( <br /> 1//0❑Owner Given Reason for D<nial W J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Pl/J o-i- o32•,Z-�{I-l6-.Z4-515.25G- coo <br /> Attach complete plans(to the County only)for the system on paper not less lhao 81/2 x 11 Inches In alze <br /> SBD-6398 (R. 01/03) <br />