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Safety and Buildings Division County <br /> ` Aff 201 W.Washington Ave.,P.O.Box 7162 U t�v rlC� <br /> iseonsin Madison,WI 53707-7162 Sanitary.Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 .I Ctt 325 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide --77- <br /> may be used for secondary purposes Privacy Law,sl5.04(I)(m) Project Address(if different than mailing address) <br /> 1. ApplicationInformation-PleasePrintAllInformation d7Qg3 N. <br /> 3 a RitHY-LK Rd. <br /> Property Owner's Name Pmcel 4 Lot q 13 Block q <br /> Jfm or en soh O/d - `1 A�8- 03400 <br /> Property Owner's Mail ng Address Property Location <br /> of 783 slV� <br /> (o al�SY. <br /> City,State Zip Cade Phone Number /V&/ NW y, Section Age <br /> iCa$SOM An IV $S9Yy 7- 775. (circlea e) <br /> If.Type of Building(check all that apply) T YO N; R <br /> (� I or 2 Family Dwelling-Number of Bedrooms &J, Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use v �ql <br /> F1 State Owned-Describe Use ❑City_❑Village ownshipof J4,AClOy <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> (�New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑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.T e of POWTS S stem: Check all that a I <br /> 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.Dis ersaVrreatment Area Information: <br /> Design Flo*Desi-g—nSoill Soil Application Rate(gpdst) Disersal Area Required(sf) Disersal Aea Proposed(sf) System ElevationSor600 �o0 9d.S- <br /> VI.Tankpacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> allons Gallons of Units Concrete Constructed Glass <br /> Existing TeaksSeptic or Ho7S-DAerobic TrwDosing ChaSOd <br /> VR.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> h'Ie-A f/o r /t �� e�ds��l 7rs= 86 6 - vs-7 <br /> Plumber's Address(Street City,State,Zip Code) <br /> 7� hL.. � W-e 6dr1Y/ l.✓� .T`y BrY.� <br /> VIII.Coun /Department Use Only <br /> Approved ❑Disapproved Sanitary Perini[Fee(includes Groundwater Date Issued Issuin <br /> x g Signature mps) <br /> El Owner Given Reason for DenialSurcharge Fee) <br /> Lr.Conditions of Approval/Reasons for Disapproval <br /> Attech complete plain(to the County only)for the syrtem on paper not los Men 811z it 11 inches in ria <br /> SBD-6398 (R. 01/03) <br />