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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 ig <br /> iseonsin M dl (08µ26633/51 X162 Sanitary Permit Numbe be filled in by Co.) <br /> Department of Commerce -LIL_(U2�G� l-/7� <br /> Sanitary Permit Application Sate Planpl.D.Number <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,05.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print AH Information MC k L <br /> Property Owner's Name P cel# iC Lot#- Block# <br /> He ' - a - K ' - l-e -N -/8 <br /> on <br /> Property Own 's Mailin ddress Property se <br /> ell k�- yy _'/., Section / 3 <br /> City,State Zip Cade Phone Number <br /> .t _/ 'S 5� Z (circle one) <br /> )/V T�N; Rr <br /> IL T of Building(check all that apply) <br /> e <br /> 93 <br /> PSubdivision Name CSMNumber <br /> �lar2 Family Dwelling-Number of Bedrooms J: <br /> ublic/Commeroial-Describe Use 4 <br /> ❑State Owned-Describe Use ❑City_❑Village Wownship of sGb <br /> IIL Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> lIR <br /> A' 13 New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Pemtit Renewal ❑Permit Revision <br /> Change ofTOmit Transfer m NewList Previous Permit NumberandDateIssuce <br /> Before Expiration Plumber <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Mound>24 inof suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑ Single Pass Sand Filter 11 <br /> Constructed Wetland P&Pressurized lit-Ground ❑Holding Tank . ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line 0 Gravel-less Pipe ❑Other(explain) <br /> V.DisitergaVrincatment Area Information: <br /> Design rea Flow(gpd) Design Soil Application Rme(gpdst) Dispersal ARequired(at) Dispersal Area Proposed(sf) System Elevation <br /> 756 _ "7 1071,25 1 ) ► 0'&91 t{(1,� 1 • 2 <br /> VI.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 12-60 01 <br /> Aerobic Treatment Unit W <br /> Dosing Chamber ,) — ' <br /> VII.Responsibility Statement-1,the undersigned,assume restasibinty for Inarnllation a[the POWTS shown on the attached plans. <br /> Plumber' ame(Print Plumber's Si MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> D k- (.OT 1" <br /> VIU.County/De artment Me Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signam Stamps) <br /> Approved ❑Disapproved Surcharge Fee) /{ C/1 Z T�y 20, O` <br /> ❑Owner Given Reason for Denial w ✓(l l/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete playa(to the Conary only)for the system on paper not lus than 812 x I l ivchea iv size <br /> SBD-6398 (R. 01/03) <br />