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Safely wd Buil dings Division Cowry <br /> ` 201 W.Wazhington Ave.,P.O.Box 7162 1 4Y A <br /> iseonsin Madisoo,WI 53707-7162 Sanitary Permit Number(to be fillorim by Ca) <br /> Department 0(Comme rce (608)266-1151 485279 <br /> Sanitary Permit Application State Plan fD Notate <br /> In accord with Comm 83.21,Will,Adm.Code,personal Informal you provide /2 8 7041 <br /> may he used for secondary purposes Privacy law,sl5 W(l gad Earned Address(ifdifleant than mailing address) r�yy <br /> 1. Application information-Please Print All Information Z9� 7L0„ <br /> Property Owners Name ParcelBlack 4 <br /> C/A r/rJ /-?"r „ an. >S� 0^ '-///7 0! 8'00 <br /> Property Owners Mailing Address Progeny Locramn COV E,(Qr <br /> `//60 T 1ly4i Gst f ae q __i, section 8 ¢ <br /> Co,'State Zip Code Phone Number <br /> N4, R 04 ,V .framer IA-Vill W 7.9 (ricks. ) C d'teoTCi, <br /> dN, R�EoQV' G 17 <br /> IL Type of Building(check all that apply) T / <br /> �lar2 Family Dwelling-Numbtt of Bedrooms 3 Suhdivisian Name CSM Number <br /> ❑PubliclCommercial-Describe Use l <br /> ❑Seem tTmmtl-Describe Use ❑City_❑V illage.(�Townsbip af,�.O '17- <br /> 111. <br /> rIII.Type of Permit; (Check only one box on line A. Complete line B ifapplicable) <br /> A11 New S,dv kBeplacement System ❑Trestmenf/Halding Tank Replacement Only ❑Other Modificasourn to Panama System <br /> R. ❑Permit Renewal ❑Permit Revision ❑Changeot ❑Permit Tramferto New List Previaus Permit Number,and Dan Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTSS stem: Check all that apply) <br /> ❑Non-Pressurical inGoopd ❑ Mound 124 in,.of surplus sail ElMound<24 in.ofsuitable soil ❑At-Gmde ❑Single Pass Sand Filler C1Constmcte!Welland 11y Pressurixad In-Uraund Holdong Tank ❑Peat Fila ❑Aerobic TrcaMcnt Unit ❑Recirculating Sand Has, ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑%m(explain) <br /> V.Dis ersaVFreatment Area Information: <br /> Design Flow(gppd) Design Sail Application Rate(Spdso Disperaal Area Requirad(sf) Dispersal Area Proposed!(so .System Elevation <br /> VI.Tank Info 4N- <br /> Was <br /> Total Number Manutucturcr Prefab Site Steel Fiber Plastic <br /> Gallons of Units Contrera Constructed Glass <br /> sepnamw,iaataT.nt <br /> Aerobic T.ra that <br /> m,mg caamw <br /> VII.Responsibility Statement-I,the undersigned,assume respomibility for instillation of the POWTS shown an the attached plans. <br /> Plumber's Name(Print) Plumber's Sinai MP/MPRS Number Business Phone Number <br /> /fie , <br /> Plumber's Address(Street.City,Spite,Zip Code) <br /> 77 //r m-e bxsllwr w J <br /> VIII.Coun /De artment Ose Onl <br /> Approved ❑Disapproved Sunitary Permit Fee(oncludes Gmundwatcr Dow hsuc0 1. g t Signa o Spmps) <br /> Surehan,Fee) y <br /> ❑Owner Given Reason for Denial It oo P 4 ;fr 04 <br /> Of.Conditions of ApprovaBRearome for Disapproval <br /> AmM complete plain on the Count,only)for currencies an paper not kin duet a@:it ixhu nation <br /> SBD-6398 (R. 01/03) <br />