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Safety and Buildings Division County p <br /> `vgy, 201 W.Washington Ave.,P.O.Box 7162 LJ r tr vt Q 1 — <br /> scons n Madison,WI 53707-7162 Sam ry PermitNumber(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 q8 <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(1Hm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information �,J.. <br /> `jOH7f arra yr 17d- <br /> Property Owner's Name Parcel 4 Lot N Block 4 <br /> /�tctiavcP Kfe(do Pt 0 A6 c/307 O/ goo <br /> Property Onwner's Mailing Address Property Location <br /> /0 90 4-K eoe- <br /> City,State Zip Code Phone Number NE '/., A"'V. Section 7 <br /> WArf%e QCs✓ /_le- /17/✓ " /1p 6Jr-/ 4y A9-867x( N, R 6(circlleene) <br /> Il.Type of Building(check all that apply) <br /> 19 I or 2 Family Dwelling-Number of Bedrooms <br /> Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> El State Owned-Describe Use ❑City_❑Village INTownship of OAkGnal <br /> III.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A. E New System y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> Non-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 ersalffreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso DispManufacturer <br /> quired(so Dispersal Area Proposed(at) System Elevation <br /> Oso VI.Tank Info Capacity in Total Number Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Talcs Tanks <br /> Septic or Holding Tank /OO /OOQ � <br /> Aerobic Treatment Unit <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) Plumber's Signatures MP/MPRS Number Business Phone Number <br /> /C/G/C f/e �Cinf +usQri' - 7.5-- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> e O �`/ 3S t r/p ds�r� <br /> VIII.Coun /De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin g Signatur o Stamps) <br /> Surcharge Fee) 50 0 r <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plow(to the County ooly)for the system on paper not los than 8112 x 11 inches in rise <br /> SBD-6398 (R. 01/03) <br />