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Safety and Buildings Division County <br /> ` m 201 W.Washington Ave.,P.O.Box 7162 Ott r n e 7t- <br /> I$'COn��� Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 472,272-1 <br /> Sanitary Permit Application State Plan I.D.Number (� <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide J1 2 V 75 <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) r� <br /> I. Application Information—Please Print AB Informationi L m a$S�0 k <br /> al <br /> Property Owner's Name n �( Parcel# Lot# Block# <br /> Orfy/�tvtOt rt.ilr�'Pvs C7(�. - `la�/.3 -ossa, <br /> Property Owner's Mailing Address _ Property Location E VR 6OV'L, (07 '7+ <br /> q/S. /?ept 144, efr <br /> Ci State -S V4> Su'%4, section /3 <br /> City, Zip Code Phone Number <br /> IOanburt (circle one) <br /> II.Type of Building T W N; R CS`E o& <br /> yp g(check all that apply) <br /> ❑ 1 or2Family Dwelling-Number ofBedrooms S1ub,diiviisionN/a�m-e CSM Number <br /> V Public/Commercial-Describe Use ©rf iC e �--CJ 1 1 esm V a ,oG C(c) <br /> ❑State Owned-Describe Use ❑City ❑village*bwnship of � <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' a New System ❑ 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 ITHolding 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(st) Dispersal Area Proposed(sf) System Elevation <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 <br /> Aerobic Tma mentUnit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,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 /> /arc/C 1 0 /Crr( � ,/Sys/ 7/S-S'66- e4/,5-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 76 0 jx'w 3�` 4t/-ebsfc.- u/.r <br /> VVIIII.Coun /De artment Use Only <br /> Id Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Z17:41 <br /> Surcharge Fee) -P V P❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plan(to the County only)for the system on paper not las than 91/2 x Il inch,in size <br /> SBD-6398 (R. 01/03) <br />