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Safety and Buildings Division County <br /> Nvisconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 ct /"/-0 e.Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 4794-1 (a <br /> Department of Commerce ! , <br /> Sanitary Permit Application State Plan I.D.Number w <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(1 xm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> 8h rrh 1\0 <br /> Property Owner's Name Parcel# Lot# Block# <br /> 70 c lep �, / o3y-/5a 7-o .2- .0 e)6) <br /> Property 0 er's Mailing Address Property Location <br /> Gov 4,(.ter 3 <br /> / y y v y f f�o��s s f eg <br /> ' <br /> City,State � Zip Code Phone Number /4, '/4, Section <br /> RGljd L)e f �f/V1 zs^�3 OO R� E �i'Xcircle gni <br /> o <br /> II.Type of Building(check all that apply) T_77N; <br /> r 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑village�40wnship of 4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 9�New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B, <br /> ❑ Permit Renewal ❑ Permit Revision ❑Change of 11 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 up 1 <br /> ❑Non-Pressurized In-Ground jXMound>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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sfj System Elevation <br /> 9P 5 <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 Bold ng-Tank 7Cra <br /> Aerobic Treatment Unit .J7 <br /> Dosing Chamberj-Ov <br /> VIL Responsibility Statement-1,the undersigned,aume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Frio Plumber's Signature MP/MPRS Number Business Phone Number <br /> �����d/n z -Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> II.Coun /De artment Use Only <br /> p ❑ <br /> proved El Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin gent Signature(No Stamps) <br /> Surcharge Fee)- f e <br /> Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plana(to the County only)for the system on paper not teas than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />