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F_ <br /> Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 u V K e <br /> Nviseons�n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Cc) <br /> �— Department of Commerce (608)266-31St 47 z95 <br /> Sanitary Permit Application Slate Plan I D Number (� <br /> In accord with Comm 83 21,Wis.Adm.Code,personal information you provide Q <br /> may be used for secondary purposes Privacy Law,a 5.04(1)(m) Project Address if different than mailing address) Q <br /> L Application Informstion-Please Print All Information 'Fq+(, <br /> Property Owner's Name �l Parcel 9 Lot 4 f-77 Block d <br /> In <br /> Property Owner's ailing Address Property Location <br /> City,State Zip Code �( /Phone Number Ai <br /> Q �A•/�'`' A• Section 110 <br /> 1r1 Yl SS3a ��,�{tccireleo <br /> 7P.b <br /> Building(check all that apply) T Z N; R(yLE or <br /> ily Dwelling-Number of Bedrooms � Subdivision Name 9 ' CSM Number 1' <br /> mmercial-Describe Use Deer ¢�k ar 4o V. V. <br /> ed-Describe Use_ E]City_L]Village NTownship of_14-L�pvV <br /> PermiC (Check only one box on line A. Complete line B if applicable) <br /> ANew System ❑ Replacement System Y p y ❑ Treatrient/Holding Took Replacement Only ❑Other Modification to Existing System <br /> 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 c of POWTS S stem: Check all that a <br /> X Nan-Pressurized In-Ground ❑ Mound>24 inof suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Send Filter ❑ <br /> Constructed Welland ❑ Pressuriwd 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 ersaVfrentmem Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> ?)00 q,;Ll Y lsb 7r '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 Ensting <br /> Tanks Tank. <br /> Septic Holding Tam c x <br /> O W1Aerobic Treatment Unit ( eS�✓ " ' <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P mber's Sign a MPIMPRS Number Business Phone Number <br /> "e-(S r f t1 6- S g 1i f <br /> Plumber's Address(Street,City,State,Zip Code) <br /> `7 ifs w d l �eLIS1Pk <br /> VIII.Coun /De artment Use Onl <br /> Approved El Disapproved Sanitary Permit Fee(includes Groundwater De[e Issued Issuin A [Si re(No Stamps) <br /> Surcharge Fee) If A,50� kW�3 , <br /> ❑ Owner Given Reason for Denial J(�/ 9 <br /> IN.Conditions of Approval/Reasons for Disapproval <br /> �1 <br /> �� I <br /> �C�M � <br /> Attach complete plain(to the Cauoty only)Por the ryahm on paper not Iran than 9111 z 11 loch o se <br /> SBD-6398 (R. 01/03) PVRNZ�+NG NN <br />