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Safety and Buildings Division County �J <br /> 201 W.Washington Ave.,P.O.Box 7162 �4 va 1e <br /> Ra Ask n Madison,WI 53707-7162 Sanitary p Permit Number(to be filled in by Co.)—� <br /> Department of Commerce <br /> (608)266-3151 496;t5 <br /> Sanitary Permit Application States Plan IQD(pN.mmbeer <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 130 (J/J-/ �J <br /> may be used for secondary purposes Privacy Law,sI5.04(I)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information ( n , <br /> UA <br /> Pro any 0 er's Name e -t-f Parcel 0 Lot fl I--1 r•BBlloc1k a <br /> NJQ <br /> �� <br /> X ��u 4 m4rcta. oa _ <br /> ProppeJny Owner's Mailing Address [�1 Property Location , <br /> Section <br /> rQ( Zp Coe Phone NumberCity,Stateg�b <br /> Y -Orole <br /> T, N, REo W <br /> II.Type of Building(checks 1 that apply) <br /> I or 2 Family Dwelling-Number of Bedrooms ' Subdivision Name CSM Number <br /> ❑PubhC/Commercial-Describe Use _ pp�t <br /> -�State Owned-Describe Use OCity_[]Village eaTownship of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y �Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B, List Previous Permit Number and Dare Issued -� <br /> [., femme Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that a I _ <br /> ❑ Non-Pressurized In-Ground 11 Mound>24 in.of sum ble soil D Mound<24 in.of suitable soil ❑ At-Grade D Single Pass Sand Filter' C' <br /> Constructed Wetland D Pressurized In-Ground X Holding Tank D Peat Filter D Aerobic Treatment Unit D Recirculating Sand Filter <br /> Recirculating Synthetic Media Filter D Leaching Chamber D Drip Line D Gravel-less Pipe D Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpds0 Dispersal Area Required(so Dispersal/vea Proposed(sp System Elevation <br /> NT.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> Ncw Existing <br /> Tanta Tal _ <br /> Sepuc r Holding Tam y <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the u dersigned,a ume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber'3 Name riot) PI tuber's Signa MPMIPRS Number Business Phone Number <br /> ?I S r r 2Z Z z 1 6 6-�66 <br /> Plumber's Address(Street,City,State,Zip Code <br /> � <br /> WoKs- L, d cs4tr U4, S Y(H3 <br /> VI .Co ad /De artment Use On <br /> , Approved D Disapproved Sanitary Permit Fee(includes Groundwater Dace Issued Issui A t Signature Stamps) <br /> 11 Owner <br /> Fee) D✓� / <br /> Owner Given Reason for Denial � <br /> Conditions of ApprovaMeasons for Disapproval <br /> Attach complete plans(to the County,only)for rhe system on paper not less than 81/2.I l Inches In,he <br /> SBD-6398 (R. 01/03) <br />