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- <br /> �— Safety and Buildings Division County — <br /> 201 W. Washington Ave., P.O.Box 7162 <br /> isconsin �`` r" (tf� <br /> Madison, ) 6-315-'/162 Sanitary Permit Number(to be filled in by Co.) <br /> _ Department of Commerce (608)266-3151 /1 M <br /> Sanitary Permit Application Stale Plan I D "umber <br /> In accord with Comm 83.21,Wis,Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s 15.04(I)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information _ <br /> Property Owner's <br /> Parcel# Lot# Block q <br /> Property Owner's Mailing Address ��6"33�-Zo -O 1- <br /> Property Location <br /> Ctry,State Zip Code <br /> Phone Num/b/e(r� Y, 44&e//" Section <br /> _ Q I'L vC•Y W r S'I <br /> y] �/� 9 N, R (cEcle W <br /> Ilrlf.Type of Building(check all that apply) 17;I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number - <br /> -____..— p cy <br /> E Puhlic/Commercial-Describe Use �7SS U. <br /> Ij i State Owned-Describe Use OCity_OVillage 1'�Township of /In t°e <br /> III.Type of Permit• (Check only one box on line A. Complete line B if applicable) ---� <br /> New System [; Replacement System ❑I reatment/Holding Tank Replacement Only Other Modification to Existing System <br /> `S i i Pennu Renewal I,J Pennrt Revision ❑ Change of LI Permit"Pransfer to New I-•isl Previous PermitNumber and Dale Issued <br /> �. <br /> Before Expiration Plumber Owner <br /> IV,--yl—of POWTS� stem: (Check all that applvl <br /> ry Nun -Pressurized In-Ground ❑ Mound>24 inof suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter 'r] <br /> ��I Constructed Welland Fj Pressurized In-Ground 11 Holding Tank L]Peat Filler ❑ Aerobic Treatment Unit ❑Recirculating Sand Filler <br /> i._R_ec_u—'u_!eting Synthetic Media Filter ❑Leaching g Ch' b Drip Line ❑Gravel-less Pipe ❑Other explain) <br /> — <br /> �_Y. Dispersal/I_reatmen[Area Information: -- <br /> Design I- ow(0j) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(n) System Elevation <br /> SOD 7VL o __ �Z, O _ <br /> Yz Y S <br /> Tank Info (:apaciy in Total Numbor Manufacturer Prcfub Site steel Tiber Plastu�� <br /> Gallons _ Gallons of lJniIs � Constructed Glass <br /> �cw <br /> Em sting"1 <br /> Ienke '1'enks <br /> �.epuc rllolding Terik / , _ <br /> Aerobic l}bnnem Umi _ <br /> �VI1. RespO nsibili[y Statement- 1,the uersigued,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's'Name(Print) PI bet's Signst a 6� Y MP/MPRS Number Business Phone Number <br /> e �� vPer 22zZF �7i _ 6-86t' <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> (ted 41 P <br /> VIIL�County/Department Use'm a -- - <br /> 'r Approved ❑ Disa�ppruved — Sanitary Permit Fee(includes Groundwater Date Issued Issui Agent Signature(No StamPI) <br /> Surcharge Fee) 7.�r��r <br /> I ❑ Owner Given Reason for Dedal <br /> IX.Conditions of ApprovaUReasons for llisapproval <br /> L_ __ _ _ <br /> Attach complete plans(to the County only)for rhe ayetem on paper nor leas than gin a]l Ineho in eine - <br /> SBD-6398 (R. 01/03) <br />