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201 W. Washington Ave P.O. Box '16'- E-)f N e- <br /> Madis <br /> � on,W1 53 07-716'_ Sanitary Puma Numbur Ito be tilled in by Co.) <br /> iscansin <br /> Department of Commerce (�g)266-afal <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm g3.21,obis.Adm.Code,personal information you provide \JV <br /> maybe used for secondary purposes Privacy Law,sl5.04(1 sem) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Informatina T ' <br /> Propaey Owner's Name n U Psted# Cot# Block# <br /> Joc"i o24. 3/o3- oz - Soo <br /> Property Owner's Mailing Addriss Property Location <br /> 2-7o33 E, 13e^so 6� CtiV:C- t2d,"801 v`on C3 3 <br /> City,State Zip Code umV.,ber _y1 Section <br /> Sew+)''".1S 14J� 7�S�f; ��J� T N, <br /> R (circle one) <br /> U.Thn of Building(e eck all that apply) <br /> %I or 2 Family Dwelling-Number of Bedrooms Subdivision Name ' CSM Number <br /> Public/Commercial-Describe Use <br /> ❑State Owned-Describe UseQCity QVitiage&ownship of J LK,- <br /> W.Type of Permit: (Check only one bo:on tine A. Complete Hue B if applicable) <br /> A. ❑New System prR placement System ❑Treaanent(Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision E3 Change of 13 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that appi <br /> 'Non-Pressurized la-Ground ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter 13 <br /> Constructed Wetland ❑ Pressurized in-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Fiber ❑Leaching Chamber 17 Drip Line 17 Gravel-less Pipe ❑Other(explain) <br /> V.Dispersaliffireatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) I Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y S,� -S- !o0 717 94. ( S- 9 3,4 <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 /> Tanto Tanks <br /> Septic or Holding Tank DOO 000 <br /> Aerobic Treatment Unit <br /> Dosing Clamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans <br /> PI ber's Name(Print) I P 's Si MP/1t4PRS Number Business Phone Number <br /> Plumber's Address(Saillet,City,State,Zi ) <br /> o <br /> VUL County/Department Use <br /> Approved 1 ❑Disapproved [Sanitary Permit Fee(includes Groundwater Date Issued Issuing t tamps) <br /> ❑Owner Given Reason for Darrel Surcharge Fee) <br /> IR.Conditions of ApprovaUReaBons for Disapproval <br /> Attach complete plans(to the County only)for the system oa paper not las than 8112 x 11 inchesin size <br /> SBD-6398 (R. 01/03) <br />