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Safety and Buildings Division County <br /> 201 W. Washington Ave..P.O. Box 7162 V('M° <br /> iseonsin Madison,WI 53707-7162 Sanitary Permit Number(m be filled in by Co.) <br /> Department of Commerce (608)266-3151 Jr JC 2p5 <br /> Sanitary Permit Application State P D. Num(beee <br /> In accord with Conlin 93.21-Wis.Adm.Cote,personal uttormarion you provide Y l cul eeJ `� 1 <br /> may be used for secondary purposes Priracy Law,sl5.04(INm) Project Address(if different than mailing address) a 1 1 <br /> I. Application Information-Please Print All Information <br /> Ca. S3Z/87-4*Lv;o0� Q d d <br /> Pr npe Owner's Name - orild✓/8'2.95•/G-eyex5 705-0W <br /> a�OfJ <br /> 7o N eNi 0163306OZ/00 <br /> Property Owner's Ma illiing. ess Property Location <br /> li 3`l l-`a^ Gov.j04, 1 .Section (7 <br /> City,State Zip Code Phone Number <br /> Ae/2 Lfet n/ 5!5U 6!Z $6 -724 z p / (circle ) <br /> 11.Type of Building heck all that apply) T ?J / N: R Ttl E o� <br /> 111 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑Stare Owned-Describe Use []City ❑Village P§Towmhip of^147 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applienble) <br /> A' ❑ New System Replacement System ?i MMMM91oldmg Tank Replacement Only ❑ Oil.Modification to Existing System <br /> B. ❑ Permit Renewal 0 Permit Revision <br /> ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S : (Check all that ) <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 Welland ❑ Pcessarized lit-Ground Y Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unk ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filter ❑Leacbing Chamber ❑Drip Line ❑Gnavd-las Pipe ❑Other(explain) <br /> V.DispersaVfteatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> //%%JJ D <br /> VI.Tank Info Gppcicy in Total Number MamufaWmer Prefab Site Steel Fiber Plastic <br /> GOons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tacks <br /> Septic or Holding Tank .ver... L nsM �l /1 <br /> Aerobic Treatment Unit W�+ ✓r/�(J C� r/ <br /> Dosing Chamber <br /> VII.Responsibility Stag - 1,the nada,assume respomWBky far Bios of the POWTS sbo m m the attached plans. <br /> PI bee's Name(Pri/n t) �``a Siger a MPIMPRS Number Business p'ho a Number <br /> Plumber's Address(Street ,City,State,Z' Code) <br /> 29ZZ0 J ,v, wed 4Ar(,j <br /> VIII.Cotmt /De ant F se Only <br /> Approved 11 Disapproved Senmry Perak Fee(includes Groundwater Date Issued Issuin nt Signa o Stamps) <br /> Surcharge Fee) // <br /> 11vers Owner GiReason for Dental ':X a41111 <br /> IX. Conditions of Approval/Reasons for Disapproral �] <br /> gw1QwD 5AC IS iMdr(�{c.I �o wrflia. f�frz_ �lva�l /dr;t df yellow EC 11 E <br /> o„ {he FIRM '�QR ✓14e1 Cua7�Y �fe ! AV9. l9, 24W8. SFE AOL <br /> *11(a„• 14k¢ jS 933.00, (( l7,c VV 4,: lttnk (.tock OCT 2 6 2011 <br /> 10:7 6le 5Ae aF fife l*AK ly d2, 0l2 <br /> Attach complete pious(to the Comy only)fpr*t system an paper mot lbs than 91/2 a Il Inches to odeRI IRNETT C04 11� <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />