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Safety and Buildings Division Counry <br /> `V;Vfy� as 201 W.Washington Ave.,P.O.Box 7162 c4el_ t� <br /> �������� Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> maybe 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 /> Property Owner's Name Parcel# Lot# Block# <br /> G cI or/Z ya/� O/moo <br /> Property Owner's Mailing Address Property Location/"L G, <br /> 6 <f_- 'A, '''A, Section <br /> City,State / Zip Code Phone Number <br /> 6 4P Ar 1/93 a �j �Ec ucle��o e� <br /> II.Type of Bui ng(check all that apply) T 74 N; RJ✓ E o`:.! <br /> or 2 Family Dwelling—Number of Bedrooms <br /> 3 Subdivision Name CSM Number <br /> �- <br /> ❑Public/Commercial-Describe Use — <br /> ❑State Owned-Describe Use ❑City, Village ownship of <br /> So.J — <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ stem Iacement News stem IS1Ye S <br /> Y r p y ❑Treatment/Holding Tank Replacement Only IJ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> ❑Change of ❑Permit Transfer to New <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> _;51�on—Pressurized In-Ground ❑ Mound>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.Dis emaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> S 6 6y 3 _0 <br /> VI.Tank InfoCapacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New P.v'sting <br /> Tanks I Tacdcs <br /> Septic or Holding Tank W/y,O O o <br /> Aerobic Treatment Unit <br /> Dosing Chamber 17.5-01756 �� <br /> VII.Responsibility Statement-I,the undersigned,anume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(P t) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ZJ e N�sla z2- 7 �� 9 -7 '6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �oX s/Y S' 1 2 <br /> VI .Coun /De artment Use Oil <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui A at Sign a(No Stamps) <br /> Surcharge Fee) dtb <br /> El1 1 -03.0� <br /> Owner Given Reason for Denial .7) <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 812 x 11 inches in siu <br /> SBD-6398 (R. 01/03) <br />