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Safety and Buildings Division County y� <br /> 201 W.Washington Ave.,P.O.Box 7162 rJ vv r-e <br /> ' <br /> Visc <br /> 11111, 201 Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 7 J <br /> Sanitary Permit Application State—/Plan I.D.Number CCl) } <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide N(� <br /> maybe used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) �J <br /> I. Application Information—Please Print All Information <br /> C. ; (E <br /> Property Owner's Name Parcel# Lot# Block# <br /> 1 mothy 1Ylahn Pt 9O —o <br /> PropertyyOOwner's Mailing Address CProGperty Locaat`ion, Z <br /> 150 7 _2k- 4 �'/., ).W '/., Section 33 <br /> City,State 11 Zip Code Phone Number <br /> u 1"RrV1Sow/ t/v� J `� 6 `10 �lS -'f63 � �qzg (circle ne) <br /> IL Type of Building heck all that apply) T3 I--N; R 19 E or�+ <br /> At or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use ,L <br /> ❑State Owned—Describe Use ❑City_❑Village'®.Township of (JL�rIVrj <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ,®New System F1 Replacement System ❑ Treatment/Holding Tank Replacement Only El 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 .'t-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.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) System Elevation <br /> LIsv Is goo 13`1 8.?R <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Sim Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> NewEvsting <br /> Tanks Tanks <br /> Septic or Holding Tank 1000 <br /> Aerobic Treatment Unit <br /> nosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa re MP/MPRS Number Business Phone Number <br /> 51E,� X61 - 3G�2 ��S- q4,3 3y � � <br /> Plumber's Address(Street,City,State,Zip de) <br /> 330aA AVeP o.Pox'7D9Ga66,bu V\i= 5 340 <br /> VIII.County/Department Use Only <br /> QS Approved ❑ Disapproved ISanitary Permit Fee(includes Groundwater Date]sued Issuing Signatu o Stamps) <br /> Surcharge Fee) ,f(. �/5 ter. <br /> ❑ Owner Given Reason for Denial Y( p( ���/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Ar6; SfsfC.n &-,Guh?nnJ OF $.2L A4 MeA V&*A)60 Al &rtm�&r l 3 f <br /> SYSj" &2Gt0_ftW of n. t 15 tVAadaWe fn Rvet- defov 6,y <br /> Attach complete plans(to the County only)for the system on paper not leas than 812 z la inches lathe <br /> SBD-6398 (R. 01/03) <br />