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Safety and Buildings Division County r�f\� <br /> as 201 W.Washington Ave.,P.O.Box 7162 S*1 r h� <br /> iseonsin Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application Sate Plan I.D.Number <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide 8J •t <br /> maybe used for secondary purposes Privacy Law,sI5.04(I)(m) Project Address(if differe "ban mailing address) w <br /> t <br /> I. Application Information-Please Print All Information ) <br /> Pro arty Owner's Name Parcel# Lot#Ste(--' Block# <br /> �acz thS-IL V0 — 06 S0 E) <br /> Prop rt Owner s N <br /> 's Mailing Address t Property Location <br /> 3/ u Idersi, rr e E, <br /> City,State Zip Code —Phhone Number —�A• —�• Section s�3 <br /> 1 111'L2u�U�[ S SS 6 / '[�/�/'� ne�l�oW�/, <br /> ,III..Type of Building(check all that apply) i ( �N; ((�E" <br /> pI I or 2 Family Dwelling-Number of Bedrooms Subdivision Name I� n � II CSM Number <br /> ❑Public/Commercial-Describe Use ' r �t <br /> 7 Slate Owned-Describe Use ❑City_❑Village Township oNJ42,O oL <br /> pConstmctedWellmd <br /> of Permit: (Check only one box on line A. Complete line B if applicable) <br /> New S stem <br /> Y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> ermit Renewal ❑ permit Revision ❑ ❑PLis[Previous Permit Number and Date Issuedore Expirationof POWTS S stem: Check all that e I ressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter' ❑ <br /> d Wetland ❑ pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ng Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsQ Dispersal Area Required(sf) Dispersal Area Proposed(si) System Elevation <br /> '7>00 a 7 Yz C/ � `?/. <br /> VI.Tank Info Cap'%5; <br /> city in Total Number Manufacturer Prefab Site Steel Fiber ptas[ic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> Ncw Existing <br /> Tanks Tanks <br /> Scpn r Holding Tank , <br /> Aerobic Treatment Urut (� <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the u designed,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P umber's Name(P n[ PI ber's Signature Rusiness Phone Number <br /> ?/ 8n MP/MPRS Number <br /> PSS oe, cls z2nz9 7r � r <br /> Plumber's Address(Street,City Slate,Zip C e) <br /> t c)4r <br /> I.Coun /De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing gent Signature(No Stamps) <br /> Surcharge Fee) L--T}�� r <br /> ❑ Owner Given Reason for Denial .JV• vV/ �'I p"Q{O <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to she County only)for the system on paper not less thaa 81/2 s I1 Inches in siu <br /> SBD-6398 (R. 01/03) <br />