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Safety and Buildings Division count <br /> ` . M 201 W. Washington Ave., P.O. Box 7162 G/ e-nJ e, <br /> isconsin Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4851 <br /> X59 <br /> Sanitary Permit Application State Plan I.D.Number <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)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information rv-,I C <br /> Property Owner's NamParcel# Lot# Block# <br /> 7 62 X00 <br /> Property Owner's Ma fling Address Property Location C-f <br /> 36o6 C r r Sw c+ ��,,O,"r <br /> City,State Zip Code cc Phone Number <br /> �b,��b,Sec[ion <br /> S i ^40/U /.%) "L) SS //O circles <br /> r,L.I1.. Type of Building eck all that apply) T L N; R �> E or V <br /> KJ 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑ Public/Commercial-Describe Use <br /> ❑Stare Owned-Describe Use ❑City_❑Village ownship of <br /> III. Type of Permit: (Check only one box on fine A. Complete line B if applicable) j r, <br /> A. )4-New System El Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System Ul i <br /> B. 11 Permit Renewal [I Permit Revision El Change of El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> 7Non-Pressurized In-Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ <br /> Constructed Weiland ❑ 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(sf) System Elevation <br /> / 7 11 sd 9so <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 Il�hrig-Tank <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Priv 0 Plumber's Signa to MP/MPRS Number Business Phone Number <br /> ai/}d t_ R v FS40/ter A)� z z 7,4 <br /> Plumber's Address(Street ,City,State,Zip Code) <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing gen gna o Stamps) <br /> Surcharge Fee) 1 �C0� kc f $ rrt,- <br /> ❑ Owner Given Reason for Denial '1T c7 Wh Vtri <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans no the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />