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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 11( <br /> isconsin Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 551 2 <br /> Sanitary Permit Application State y�D. Numher Qi <br /> In accord with Comm 83.21.Wis.Adm.Code,personal information you Provide �o�, 9—ul �1 <br /> may be used for secondary purposes Privacy Law,sl5.04(lXm) Project Address(if different than rmiling address) <br /> 10 <br /> I. Application Information-Please Print All Information 1� 2�a ) <br /> Propewner's Name Parcel Lm 6 Block p <br /> / ,1$-5 CS-cnz-o/ <br /> u <br /> Property Owner Ma fling Address Property Location <br /> �u mfr �� 6ov=�. �Z. <br /> %, -A,Section � <br /> City,State Zip Code Phone Number <br /> � Wl (circle ) <br /> AmenT N; R_WE or& <br /> II.Type of Building(check all that apply) <br /> 1 or 2 Family Dwelling-Number of Bedrooms CSM Number <br /> ElPublic/Commercial-Describe Use L.oT 9 GSM ti!/, / SG s �deea( In <br /> ❑State Owned-Describe Use ❑City_❑village wowmbip of (A <br /> III.Type of Permit: (Check only me box on lira A. Complete tine B if applicable) <br /> A. ❑ New System Replacement System ❑Tramnem/Widimg Twk <br /> Replxement Only ❑ Other Madficazion 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 Owns <br /> IV.Type of POWTS System: (Check all Mat ) <br /> ❑ Non-Pressurized In-Ground ❑ Mound > 24 is of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Welland ❑ Pressurized In-Ground 1V holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filter ❑Leaching C7ramber ❑Drip Line ❑Gravel-less Pipe ❑Odtcr(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application RaWgpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank InfoCapacity in Tout NumberMatarfaceaer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New I Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /1t <br /> Aerobic Treaueetn Unit W <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume rely fm bastallsaim of the POWTS sbown on the attached plan. <br /> PI is Name(Prin t) I 's Signs MP/MFRS Nwo6er Business Phar Number <br /> oA649f <br /> Plumber's Address(Street ,City,State, N <br /> 27220 ;�j %'�l Vekav- 'WL` y <br /> VIII.County/Re ent Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater I Date Issued!// Issui t Sigmtur mps) <br /> ElOwner Given Reason for Denial <br /> Surcharge FCC) <br /> ^ <br /> IX. Conditions of Approval/Reasmis for Disapproval <br /> SI 15 A%9Po(- a5 urrUIii -6we. F/046, fish of (Atnev�a�Cfa�Ib4ry J-4Vr_ <br /> See- fi k4i k-e 6(-4e� Rrc C)40,0 <br /> Attach complete plus(to the Coyly ad»for the., on paper not les than 6112 x It aches in size <br /> SBD-6398 (R. 01/03) <br />