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0 <br />Safety and Buildings Division <br />201 W. Washington Ave., P.O. Box 7162 <br />County <br />do fw,f <br />wnsi n <br />Madison, WI 53707 — 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />Department of Commerce <br />(608) 266-3151 <br />Y <br />Sanitary Permit Application <br />State Plan I.D. Number <br />/ <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 xm) <br />Project Address (if different than mailing address) <br />J A.,� <br />1. Application Information Please Print Information <br />— All <br />Properly Owner's Name <br />Parcel # Lot # Block # <br />or/ -AV _O/fto <br />Property Owner's Mailing Address <br />Property Location <br />2 oO� ` ` l .^/ <br />ME '/4, .'/., Section Al <br />City, State <br />Zip Code Phone <br />Number <br />F 411• is-,Velo <br />V" <br />%e. / <br />�( ircle ore) � � �qe� <br />T N, R is E orr `Q <br />11. Type Building that <br />of (check all apply) <br />Subdivision Name CSM Number <br />I or 2 Family Dwelling - Number of Bedrooms <br />❑ Public/Commercial -Describe Use <br />❑City Village Township of jW IWI✓ <br />❑ State Owned- Describe Use <br />1II. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A, <br />,® y <br />New System <br />El Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />El Other Modification to Existing System <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />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 Wetland ❑ Pressurized In -Ground YHolding 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/Treat ent Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total <br />Number <br />Manufacturer <br />Prefab <br />Site <br />Steel <br />Fiber <br />Plastic <br />Gallons <br />Gallons <br />of Units <br />Concrete <br />Constructed <br />Glass <br />New <br />Existing <br />Tanks <br />Tanks <br />Septic or Holding Tank <br />Z066 <br />rJ 0 t <br />!I / <br />/ 'f/✓ <br />7 <br />Aerobic Treatment Unit <br />Dosing Chamber <br />VII. Responsibility Statement- 1, the undersigned, a ume responsibility for installation of the POWTS shown on the attached plans. <br />Plut ber's Name ;PFr't) !/ <br />Plumber's S n re <br />MA/MPRS Number <br />e5'19Sy <br />Business Phone Number <br />5 /mli� <br />Plumber's Address Street, City, State, Zip ode) <br />V <br />G J� Vdk 1*- w • �r g <br />VIII. Coun /De artment Use Only <br />proved <br />❑ Disapproved <br />Sanitary Permit Fee (includes Groundwater <br />Surcharge Fee) <br />I <br />Date Issued <br />Issuing Agent Signature (No mps) <br />❑ Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval <br />r+uncu wmpmac In— ttv me a.uunry Orly/ r e SySrenrOn-po t leis than 511L X r r InCheS in SiZe <br />A -A <br />SBD-6398 (R. 01/03) <br />