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Safety and Buildings Division County <br /> Visconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 r <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 8311,Wis.Adm.Code,personal information you provide /6632- <br /> a W) 1 <br /> maybe used for secondary purposes Privacy Law,sl5.04(I)(m) Pmjeet Address(ifdiffer®t thmlym'-ailing address) W <br /> L AppBatloe Information-Please Print AB Information /) 30q a S /vdme/�+�1 I -TrY <br /> Property owner's Name (-, J" <br /> Paul# l.ot# Block# <br /> OA- s-l/6 -oy3 (Do <br /> Property Owner's Mailing Address Property Locative <br /> 6'00L-4j& 7 <br /> City,Side Zip Code Phone NumberV.7 — _Vk Section / 6 <br /> 6b Lsbc( 1,1 ) <br /> ( - derT9 N: R� (circle mo) <br /> IL Type of Building(check all that apply) S <br /> Subdivision Name CSM Number <br /> ❑1 m 2 Family Dwelling-Number of Bedrooms r,, <br /> ®.Public/Commereial-Deacdbe Use � <br /> ❑Stare mb <br /> owned use ❑City❑Villoge aasto—abip of/jf.b)/ Lc <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable)o -03 <br /> A' J344.System 0 Replacemrnt System 0 Treamient(Howing Tank Replacement Only 0 Other Modi ication to Existing System <br /> B. 0 Permit Renewal 0 Permit Revision 13 Change of 11 Permit Transfer in New Lid Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS 3 m: Check all that apply) <br /> laFNon-Prnsuriaed mcrorma 0 Mmmd>2Aro.of suitable acid 0 Mound<24 m.of suitable soil 0 At[aade 0 SinglePass sand Filter 0 <br /> Constructed wetland 0 Pressmiad mcroana 0 Lloldmg T=k 0 Ped Filter 0 Aerobic Treatment Unit ❑Recvculating Sand miter 0 <br /> Recimdding Synthetic Media Filter O laacltmg Chamber 11 Dnp Lame 0 Grovel-leas Pipe 0 other(explain) <br /> V.Dispersalfrreatment Ara Information: <br /> Design Flow(gpd) Desigo Soil Application Rate(gpdaq D®pcsai.Arra Requved(so Dispersal Arra proposed(at) Sysem Elevation <br /> z _ 7 J J . ?�c 1?3 <br /> VI.Tank Info Capacity in Total Number dura Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constnu:ted Glass <br /> New Exis <br /> Tsda Tadd <br /> Septic or Holding Tadt <br /> 1 G <br /> Aerobic Tredmem Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the sed an dMllty for inslalli don of the POWrS shown on the attached plana. <br /> Plumber's Name(Print) P s MP/MPRS Number Brennan Phone Number <br /> John Solofra #223779 715-376-2278 <br /> Plumber's Address(Street,City,Stile,Zip Code <br /> PO Box 161; Gordon, WI 54838 <br /> Yin <br /> Only <br /> .Com /De rtment Usepprovcd ❑INeapproved Sanitary Permit F (includes Groundwater Date Issued t Signdme(No Stamps) <br /> Sumharge Fee) Sas 00 -5-7170 1 <br /> ❑Owmer Given Reason for Denial <br /> UC.Conditions of Approval/Reasons for Disapproval <br /> Attach compilers plaac(to the County only)far the system oa paper no less thn SI/2 111 laches in sire <br /> SBD-6398 (R. 01/03) <br />