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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Pt•e q <br /> %sconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 8,5 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide Z <br /> may be used for secondary purposes Privacy Law,s I5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information—Please Print AB Information ��..11(JZ5 a-+! e 4 / V/ <br /> Z5 J�n P IIG <br /> Property Owner's Name Parcel# Lot# 3 Block# <br /> r d ix 020-I ' 101.= <br /> Property Owner's Mailing Address Property Location <br /> _'/., _Y., Section 33 <br /> City,State Zip Code Phone Number <br /> iee;lfa r S 7�J -"f — qO /�'��(circleon <br /> II.Type of Building(check all that apply) T� Name or <br /> (�I or 2 Family Dwelling—Number of Bedrooms Subdivision/Neme CSM Number <br /> ❑Public/Commercial—Describe Use Y v • � <br /> ❑State Owned—Describe Use ❑City_❑Village JOTouriship of qIts <br /> 1R.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. X 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 of POWTS System: Check all that apply) <br /> y.�yNon—Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Welland ❑ 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.Dispersal/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> 3( 1 . 7 "9 Y-K-0 97 0 <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 /> Own <br /> olding Talc IV <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the 4ndersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) umber's Sign ure MP/MPRS Number Business Phone Number <br /> P(S P. - kxa27zT ZZ Cr 7/r 64pl? <br /> Plumber's Address(Street, ity, tato,Zip Code) <br /> -7Wir Cot.w W- UjC6_4er, CJ,' -TVYr3 117 <br /> VIII.Coua /De artment Una Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issum Sign o Stamps) <br /> Surcharge Fee) f <br /> El Owner Given Reason for Denial oCiN�/W PTA <br /> IR Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 812 x It inches in sire <br /> SBD-6398 (R. 01/03) <br />