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Safety and Buildings Division County <br /> Visconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 vamt-r Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) / <br /> Department of Commerce (608)266-3151 /I C <br /> Sanitary Permit Application State Pla`II..D.Number 7 <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,a]5.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name a Parcel Nom/ Lotft Block# <br /> Property Own Mailing A tars •Property Location <br /> I1S C- In <br /> City,State Zip Code Phone Number —�' —�• Section <br /> S e 1 SGIBo �,s 63s aGa1 1�(cucle qpe) <br /> it.Type of Building(check all that apply) <br /> T 7�1 N; R1 E ol/aJf'� <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ,Xrublic/Commercial-Describe Use CQYls11A <br /> El State Owned-Describe Use u ❑Ci ❑Villae}q� <br /> ty_ g Icyownshipof uS� <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 21 <br /> New System El Replacement System ❑Trea[mrntMolding Tank Replacemrn[Only ❑ Other Modification m 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 /> �IvV.Type of POWTS S stem: Check all that apply) <br /> la1 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> I M51 <br /> X13 L1'1 <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 1 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> r <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) V Pto bet's Signa MP/MPRS Number Business Phone Number <br /> Sc <br /> Plumber's dress(Street,City,State,Zip Code) <br /> b/v 5 /Ake Lkle w s g76 <br /> VIIkCountvfDepartment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin ge ignatu Stamps) <br /> Surcharge Fa) � � <br /> ❑Owner Given Reason for Denial `F( �(,/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 812 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />