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Safety and Buildings Division County � 2�� 7201 W.Washington Ave.,P.O.Boz 7162 1 <br /> -7162 Sanitary Permit Number(to be filled in by <br /> Visconsin Madison,WI 53707 Co.) <br /> Department of Commerce (608)266-3151 47$ 40 <br /> — <br /> Sanitary Permit Application Sate Pian I D Number <br /> In accord with Comm 8321,W is.Adm.Code,personal information you provide 114 51 11d <br /> may be used for secondary purposes Privacy Law,s15.04(l)(m) Project Address(Tditferent than mailingaddress) <br /> �1. Application Information-Please Print All Information _y),,3,rsaq <br /> Property Owner's Name 'y"i U Parcel N Lot Block p <br /> JzWe( Joh ov, o� _ -o <br /> Property Owner's Mailing Address Property Location G Ov l�. <br /> .3 O � e i h b Y, /., y,, section <br /> City,State Zip Code Phone Number <br /> �6- '(,/( <br /> s V T VON, R�Ecor� <br /> r11A <br /> I.Type of Building(check ell that apply)<1 or 2 Family Dwelling-Number ofBedrooms Subdivision Name CSM Number <br /> Public/Commercial-Describe Use Lara CIS <br /> ❑State Owned-Describe Use DCity, ❑Village Township of GO _ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> —.—. - --- <br /> Al <br /> .I New System Replacement System D TrewmenUBolding Tank Replacement Only D Other Modification to Existing System <br /> B. D Permit Renewal ❑ Penn it Revision D Change of D Permit Transfer to New List Previous Permit Number and Data Issued <br /> Before Expiration Plumber Owner <br /> IV.T e of POWTS Sys[em (Check all that applvl --� <br /> Non-Pressurized In-Ground D Mound>24 inof suitable soil D Mound<24 inof suitable soil D At-Grade D Single Pass Sand Filter 1_i <br /> Constructed Wetland D Pressurized In-Ground Molding Tank D Peat Filter D Aerobic Treatment Unit D Recirculating Sand Filter C <br /> Recireulahng Synthetic Media Filter D Leaching Chamber D Drip Line D Gravel-less Pipe D Other(explain) <br /> .l 4'. Dis ersalffreatmant Area Information: <br /> F <br /> Design F�lo-w�(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) ;DispersalAreased(sf) System Elevation <br /> 7a nk�o Capacity in Total Number Manufacturer SiteSteel Fiber plas(ic <br /> Gallons Gallons of Units e Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Sc� poc Holding Tx K ^7,7 <br /> Aerobic Treatment Unit —1 <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the u ersigned,assume responsibility for iostallation of the POWTS shown on the attached pia as. <br /> Plumber's Name(Print) Pll ber's Signat a MP/MPRS Number Business Phone Number <br /> PSS L4 rpt(/ <br /> Plumber's Address(Stree,City,State,Zip Cod ) <br /> ��S <br /> VI I.Coun /De artment U Onl <br /> Approved ❑ Disapproved Sanitary Perm�43U�v <br /> Data Issued Issuin gel igri o Stamps) <br /> Surcharge Fee27 <br /> Owner Given Reason for Denial <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach complete plum(to the County ovly)far[he rystem w paper vat leas than BIR r 1 I inches in siu <br /> SBD-6398 (R. 01/03) <br />