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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> ` ,c�O�cI� Madison,WI 53707-7162 Sani Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-315172 z <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,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Informs n <br /> Property Owner's Name Parcel# Lot# Block# <br /> C9db C odeI---I CU <br /> Property Owner's Mailing Address Property Location <br /> &L <br /> o 3 <br /> Section <br /> City,State Zip Code Phone Number <br /> Aire I/t Ct✓ IOWA/ S-21-11A b T 4(L N; Rhe oe�) w <br /> xI.Type of Building(check all that apply) <br /> 'r1 or 2 Family Dwelling-Number of Bedrooms n <br /> el Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use Y 92 0 a l <br /> ❑State Owned-Describe Use ❑City_❑VillageNTownship of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. IJPermit Renewal ❑Permit Revision ElChange of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> � <br /> IV.T of POWTS System: Check all that apply) <br /> SLY�qqNon-Pressurized In-Ground ❑Mound>_24 in.of suitable soil ❑ Mound<24 im 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 6v0 I . -7 gti --7 r6#/ 970 0- <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 t'h�� /,A r0 <br /> -f�7 s a w x <br /> Aerobic Treatment Unit — <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> R f o/c f fo /L:n1 /?,cic.+*s JSBS/ yfS-�G 6- e,,iS'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> o47760 fftA- W�bsf�✓ ''v�s`/S9� <br /> VIII.County/Department Use Only <br /> Approved Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu' ent Si re(No Stamps) <br /> Surcharge Fee) � � �( <br /> ❑Owner Given Reason for Denial '(77-(J't' 4a441 /AlYMAk�- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plass(to the County only)for the system on paper not less than 81l2 x 11 Inches in sire <br /> SBD-6398 (R. 01/03) <br />