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I <br /> Safety and Buildings Division Countyp <br /> Visconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 `�uYheft <br /> Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 495 <br /> /a <br /> Sanitary Permit Application State Plan I.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,a 5.04(1)(m) Project Address(if different than mailing address) <br /> 1. ApplicationInformation-Please Print Alllnformation �Y 6517 VP-f. Dr- <br /> Property Owner's Name Parcel# Lot# Block# <br /> Uorx tkklkcr- 06%0 43N 06300 <br /> Property Owner's Mailing Address Property Location <br /> 9348 S. 67,&4 Sy- Sw '/4, SW Section 14 <br /> City,State Zip Code Phone Number <br /> 4�,Csrt_t C N s$016 611 467- a IDJJ circle ) <br /> II.Type of Building(check all that apply) T 40�N; R Z6 E or�V ( ` <br /> Z I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name `CSM Number W <br /> 11 Public/Commercial-Describe Use V L -54/0/ ```" Vr V to. /8/ 3-- <br /> ElState Owned-Describe Use ❑City ❑Village95Township of OA/045" A 4_ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ,( New System El 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 S stem: 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 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 crsal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 451O 1 . 7 643 649 1 95.9 q4-5/A1.9 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /000 /000 <br /> Aerobic Treatment Unit <br /> Dosing Chamber (0 00 <br /> VI 1.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 Number Business Phone Number <br /> / Ick H! klhl J.ASBS/ 7/s' 866 - C1 5*7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> JL776 ['T D .s.r 3S t.✓2(asiF+r.- fl- r j, 3 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signatu o Stamps) <br /> Surcharg a Fee) / <br /> El Omer Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less than 812 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />