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Safety and Buildings Division County <br /> Asconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 '5v A>vE 7'T Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266.3151 Tc Q 28 <br /> Sanitary Permit Application State Plan l.D Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 1 3 Z 3+4-5 <br /> maybe used for secondary purposes Privacy Law,s15.04(1 xm) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information <br /> Ja -- (/c)_ -a <br /> Pro rty Owner'sryame Parcel k Lot k Block# <br /> i4�fa W (ti^ I CSvI Upl 9 Wb <br /> Property Owner's Mailing Address Property Location <br /> o(e 9 vt, P CRW Q G <br /> Ci ,State r Zip Code -P7hone Number/ ' —'a-�� Section <br /> 6N4­ Ll.f1 ``�K'� ( //S �3J (circle one) <br /> T _N; R-(!�__�'or W <br /> I . pe of Building(check all that apply) , <br /> Subdivision Name CSM Number <br /> ❑ I ort Family Dwelling-Number of Be'Qlrooms I <br /> 'E Public/Commercial-Describe Use KtCL(X tPrVjt lt-g Z <br /> El State Owned-Describe Use ❑City_❑ �7Village FiTownship of }�u5K <br /> 111.Type of Permit: (Check/Re lacement stem only one box on line A. Complete line B if applicable) <br /> A. El New y New S S <br /> System J p y ❑ 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.Type of POWTS System: Check all that apply) <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 Aolding 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(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) 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 /> Naw Existing <br /> Tanks Tanks <br /> Septic or Holding Tankt <br /> C VJtE •o'' <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- t,the and igned,assre responsibility for installation of the POWTS shown on the attached plans. <br /> PI u ber's N (Pr'nQPlu r' ignat MP/MPRS Number Business Phone Number <br /> ° 2252 Q /S 3752 <br /> u ber's Add re (Street,City,State,Zip Code) <br /> J B.( ?,&e f l�N- W s SLQ-6 <br /> Vlll.Coun /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date IssuedIssuin t Signal o Stamps) <br /> Surcharge Fee) Soo ap /' Z <br /> ❑ Owner Given Reason for Denial / V <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less than 91R x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />