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Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 <br /> iseonsin Madison,WI 53707-7162 Sanitary Permit u ber(to be filled m by <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan LD Number <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(l)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information 00�� <br /> Property Owner's Name %IJ ,Q Parcel# Lot#,�y Block# <br /> vJ f f' � ✓ SorJ ado X330 <br /> Property Ouster's Mailing Address Property Loca ion <br /> 7 5^� 6 S7, 19, <br /> city,Seim Zip Code Phone Number _V, Section 74 <br /> 0-Y-77 755 �i(circI ) <br /> ' <br /> Il.Type of Buil g(check all that apply) T�GN; RJ E o v✓ <br /> P.1 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision NameLLL CSM Number <br /> .-4Gtes <br /> ❑Public/Commercial-Describe Use dSe �F'e S�rze <br /> El State Owned-Describe Use -- ❑City_❑Villa ewnship of <br /> Ic 4 <br /> Q a,ip� <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �k ,� System stem <br /> `� y ❑ Replacement System ❑ TrealmenVHolding Tank Replacement Only El Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to Now List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stem: Check all that a I <br /> ANon-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 ❑ I-loading Tank ❑Peat Filter ❑ Aerobic I reannent Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersal/Treatment Arca Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsQ Dispersal Arca Required(sl) Dispersal Area Proposed(st) System Elevation <br /> 06 S 600 60 0 <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 75- <br /> 6 <br /> 1� <br /> Aerobic Treatment Unit <br /> Dosing Chamber ..— <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW'TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> Cv�1�/t� �Pvf". Gln G✓ �z�6q/ 3yp -7.2P1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /.3 oX-5,-X 41 s'.�-e -.-) " s-gro7-7- <br /> NIL[. <br /> V 11.Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit F (includes Groundwater Date Issued Issum gent Signature(No Stamps) <br /> Surcharge Fee) 4l 05D.t-v-) 'I�f�� �� <br /> ❑ Owner Given Reason for Uonial �ttf IIY" O�+J U•LTJ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plant(to the County only)for the system nn paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />