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At <br /> Safety and Buildings Division County ' <br /> ` 201 W. Washington Ave., P.O. Box 7162 <br /> �sconsin Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 g,I 22� <br /> Sanitary Permit Application StateetPlan I.D. Number <br /> In accord with Comm 83.21,Wis. Adm.Code,personal information you provide /2 7567 <br /> may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# Lot# Block# <br /> L A urA �err,1 � w 0o 2 / o < G <br /> Property-: — ' Mang Address "i � Z_ K '\ v Property LocationP C / <br /> City, K SW ''!�w '/.Section <br /> Y Zip Code Phone Number <br /> s ? <br /> F r C �...1 /�J 7 / / / — "e O 34 j (circle one) <br /> II. Type of Building(check all that apply) T N; R �/ E or V© <br /> 'tTor 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑ Public/Commercial-Describe Use ----- <br /> ❑State Owned-Describe Use -- [Icily_(] illage Aownship of <br /> III. Type of Permit: (Check only one box on line A. Complete it..B if applicable) <br /> A. <br /> ' New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification m Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New Lis[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 ❑ 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/1 reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> So , S 5/ S /f 5-d 99,/.S <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 ldekitsg-T'enk <br /> Aerobic Treatment Unit <br /> Dosing Chamber ./ <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(P o / Number's Signa ture MP/MPRS Number Business Phone Number <br /> .7Y19 <br /> Plumber's Address(Street ,City,State,Zip Code) <br /> VIII. County/Department Use Only <br /> , <br /> Yl Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing a Signa o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />