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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 SW h <br /> Visconsin Madison,8) 6-315-7162 San i arnthmmailing <br /> �(ty be filled in by Co.) <br /> De artment of Commerce (608)266-3151 Lt <br /> Sanitary Permit Application Sate INu <br /> mber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 1may be used forsecondary purposes Privacy Law,sl5.04(lxm) Projecthan mailing address)L Application Information-Please Print AllInformation 'LMCProperty Owner's Name P celLot# Block# <br /> N e a - K ` t9 cA C K- )-e -N 7-/8 <br /> Property Owne's MailingAddress Property W tion <br /> 1 _%., _Y Section / 3 <br /> City,State a Zip Code Phone Number <br /> 1,rt� S �� -� (cbcleone) <br /> IL T of Building(check all that apply) T N; R r <br /> 91 or 2 Family Dwelling-Number of Bedrooms 5 Sub'diviiission Name /v' CSM Number <br /> Public/Conanemial-Describe Use 4 r�R c Al e- C 21 if e,4 <br /> ❑State Owned-Describe Use City Q illagc0owaship of sGd <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New SystemI� <br /> q Replacement System ❑TreatmrnNHolding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of [3 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 ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Weiland R.Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line Cl Gravel-less Pipe ❑Other(explain) <br /> V.Die ersal/Preatment Area Information: C <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal AreapProposed st) System Elevation <br /> 7-SO - 7 1071-25 17 10$S.S 90. ? <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel I Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Talcs <br /> Septic m Holding Tank 2 6 oo r ( /r <br /> Aerobic Treatment,Unit <br /> Dosing chamber 1 — i <br /> V11.Responsibility Statement-I,the undersigned,assume nsibinty for Installation of the POWTSS/shown on the attached plans. t! <br /> Bustiness <br /> hone Number <br /> Pj,.t.i f l 1 1� n,L(ti�k'10L Plumber's SiLpfflume MPMIP�RS�V P/ <br /> Plumber's Address(Street,City,State,Zip Code) et Io <br /> Lo 19W Qv w . S r i r t5 D k- 5 <br /> VIM.Coun /De artment Uge Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signatu Stamps) <br /> Surcharge Fee) <br /> ❑Owner GivenReason for Denial �✓(l TW Ot DL <br /> LY.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plane(to the County only)for the system on paper not las than 812 s I I inches hider <br /> SBD-6398 (R. 01/03) <br />