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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 /3o,e.n-e& <br /> lVisconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 +7Z 2 90 <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(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information q-7 -7-<&y L k 5o en L/i <br /> Property Owner's Name Parcel# Lot# Block# <br /> ken Goo Op - `7/70- of 600 <br /> Property Ow/tier's Mailing Address Property Location <br /> 7s"6 H Ga oon try L�'Y,, Section ! <br /> City,State Zip Code Phone Number <br /> �t/� fPv ti/1 Se! 3 7s--Mo- 86 3/ (circle one) <br /> T�O N; R /(1 E or(5 <br /> 11.Type of Building(check all that apply) <br /> O'1 or 2 family Dwelling-Number of Bedrooms <br /> 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use I <br /> ❑State Owned-Describe Use ❑City_ Village Township of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ,-New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal El Revision Change of El Transfer to New <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> KNon-Pressurized N-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 4s-o - 7 648 9s, y <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 /490 OOO <br /> 17 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> H(OOO <br /> �d <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown an the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rleft o ,„ �?.-�+ •cP �'J susl �s=�6�-4/S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .97;r6 //� 3s ry 6str. Gt/1 s��9 <br /> II.Court /De artment Use Only <br /> proved ❑ Disapproved Sanitary Permit Fee includes Groundwater Date Issued IssuiSrg Agent Signature`(No Stamps) <br /> Surcharge Fee) ' �i D, � 61(ol <br /> ❑Owner Given Reason for Denial ��f-f� tX-7 U <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ED IT-7 <br /> c � <br /> 0ji <br /> I <br /> f <br /> Attach complete plow(to the County only)for the system on paper not less than I1 Inches i f s J C r <br /> BURNS L'_ <br /> SBD-6398 (R. 01/03) z N N®UN7)/ <br />