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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Ou r rl e 71f- <br /> iseonsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 47L2 5 5 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 53.21,Wis.Adm.Code,personal information you provide 1 1 ZV)729 <br /> may be used for secondary purposes Privacy Law,at 5.04(1)(m) Project Address indifferent than mailing address) <br /> 1. Application Information-Please Print AB Infarmati AFI <br /> -�TO <br /> - <br /> Property Owner's Name Y/O Parcel-## (p Lot#g j q Block# f <br /> David Sc AaeAlee-ke0311%. - 7WO- o/- (900 <br /> Property Owner's Mailing Address Property Location <br /> 3109Nenn en %vc S, d g <br /> City,State Zip Code Phone Number —��'' Section <br /> M 12 44 /17AlSS yo (circle�oµµe) <br /> T NI N; R/L EOIOV <br /> II.Type of Building(check all that apply) <br /> ❑I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> Public/Commercial-Describe Use 84r s'Ps���"4^'r Orr Ina(T�, of Wq&J24 <br /> ❑State Owned-Describe Use 0City_9Village Fownahip <br /> " c <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `t' ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only 5t Other Modification 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 Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑ Non-Pressurized fi-Ground ❑Mound>24 in.claimable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground XHolding 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(so Dispersal Area Proposed(so System Elevation <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 Took <br /> Aerobic Treatment Unit <br /> Dosing ClMlOber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signature MP/MPRS Number Business Phone Number <br /> Wo, in s I R-c� 1 'P/.f 6 f- C//S7 <br /> Plumber's Address(Strait,City,State,Zip Code) <br /> .2 7764 ,,// <br /> V,IH.Coun /De artment Use Only <br /> Id Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater I Date Issued Issuin en 'ignature tamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial �J W <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> L MIN <br /> Q (KA <br /> m <br /> APR I A 2005 <br /> Attach complete plow(to the County only)for the systeon hu than {Sll paper not an sl/2 x 111orJgy ipO ,E COUNTY <br /> F1IVI I ZONING <br /> SBD-6398 (R. 01/03) <br />