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Safety and Buildings Division County /� <br /> 201 W.Washington Ave.,P.O.Box 7162 /,�fdt/ <br /> Visconsin Madison,WI 53707-7162 Sanitaryo Permit Number(to be filled in by Co) <br /> De artment of Commerce (608)266-3151 �-tt7 Jr" eo <br /> Sanitary Permit Application StatesPlan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide A•q 3 9315 <br /> may be used for secondary purposes Privacy Law,sI5.04(I)(m) Project Address(if different than mailing address) <br /> 1. Application Information—Please Print All Inform ipin 8Q!\ <br /> Property Owner's Name /V Parcel k Lot k//y,/7��lock N <br /> G/1 r� ��fjs O� 92ov <br /> Property O er's Mailing Address Property Location <br /> c <br /> /z 7 I,'rre ^ ,/ s c,'f_ -2a <br /> City,State Zip Code Phone Num-beer / /���• �A• Section <br /> Z,14-f$ X U Gc/T yy� 3 7�S- �/S—( a/5� 7/J // Ec it one) <br /> T N; R E <br /> II.Type of Building(check all that apply) 3 <br /> �-1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name CSM JNum f 1 <br /> ❑Public/Commercial—Describe Use Kl/9l-ke C_/�(/ber <br /> El State Owned—Describe Use ❑City_❑Village% ship of <br /> Ill.Type of Permit (Check only one box online A. Complete line B if applicable) <br /> A. VNew 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 ItrMound>24 in.of soluble soil ❑ Mound<24 in.of suitable soil El At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ I folding Tank ❑feat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Fiber ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersal/freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsq Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> Z15-2 . 5 5v 1 9 y 6 <br /> I.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New I Existing <br /> Tanks Tanks <br /> Septic or Holding Tank ;t� <br /> Aerobic Treatment Unit <br /> Dosing Chamber e 0�) <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 Signature MP/MPRS Numbcr Business Phone Number <br /> Gd 1e_ <br /> Plumber's Address(Street,City,State,Zip Code) ` p <br /> VIII.County/Department Use Only <br /> ❑ Approved ❑ Disapproved Sanitary Permit Pee(includes Groundwater DateIssued Issui Agen ignature tamps) <br /> Surcharge Fee) / <br /> El Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attuh complete place Ifo the County only)for the system on paper nut less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />