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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> u r n Ne. <br /> Madison,WI 53707—7162 Sanitary�Permit Number(to be filled in by Co.) <br /> ? <br /> De artment of Commerce (608)266-3151 u5/e <br /> Sanitary Permit Application Sale Plan I.D.Num✓be <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04HXm) Project Address(if different than mailing address) <br /> 1. ApplicationInformation—Please Print All lnfoyfl7ption /r}$FIQh slr'LP.h w4Y <br /> Property Owner's Name Parcel# Lot# 3 Block# <br /> De YCrit Alf 6_&M 0 \I 9300 0 46,06 <br /> Property Owner's Mailing Address Property Location <br /> 30 ado (!�*r sem , w 7 <br /> /., N %, Section <br /> City, <br /> y�State Zip Code Phone Number <br /> <-f6N.de.r W..0 S�`f8 3 d 44-1 p7S /I f r� y p (circle ) <br /> T N; R�y E or V 5 <br /> If.Type of Building(check all that apply) W <br /> &1 or 2 Family Dwelling—Number of Bedrooms '? Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use f�evV <br /> El State Owned—Describe Use ❑City ❑VillagegTownshipof seort <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Al New System y [I Replacement System ❑Treatment/Holding Tank Replacement Only El 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 /> aI#V.Type of POWTS System: Check all that apply) <br /> yi 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 erind/freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sD System Elevation <br /> 'fSD . 7 6 `U 6/{8 17A .M- 9 3. <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 Holding Tank /660 /p Or) sTt <br /> 4'ea, X <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 Signature MP/MPRS Number Business Phone Number <br /> /? ItAc1s/Okrav la.4 2Q7Fo�6�&c:.., <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 01.776 0 !yt-r 3S' "e ,c_6-1 2e i aa,F a"/{893 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A ignature tamps) <br /> Surcharge Fee) �� rrJ k` z� -y s <br /> ❑Owner Given Reason for Denial 'lP ! 6 t/1/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in site <br /> SBD-6398 (R. 01/03) <br /> F I <br />