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Safety and Buildings Division County -f <br /> m 201 W.Washington Ave.,P.O.Box 7162 �Jt <br /> �Visconsin <br /> Madis on,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 1 Q 5 2)9 <br /> State Plan I.D.Number <br /> Sanitary Permit Application <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) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> o�48y 3 �.ek�waucf d),c.. <br /> Property Owner's Name Parcel# Lot# L Block# <br /> a/v . Eta d3Y-�s ,I Doo <br /> Property Owner's Mailing Address Property Location / U 4 o Y-/ <br /> d ! / Sf. 5f. Al <br /> ` /<, '/4, Section l <br /> City State <br /> 9Zip Code / PQhone Number <br /> d KI/,`� AA01. S T 23 d-512" 9JS r DVO / <br /> T�N; Rr (circle ) <br /> o <br /> II.Type �E of Building(check all that apply) ^� <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ElState Owned-Describe Use ❑City_❑Villag ownship of a a 6- <br /> G" <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. El Permit Renewal El Permit Revision El Change of ❑Permit Transfer to New <br /> 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 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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> L?7, <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 o olding T / <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for insta the POWTS shown on the attached plans. <br /> Plu ber's Name(Print lumber's Signature /IyIPRS mber Business Phone N7umL bber <br /> 0 Ns��/�9.. 1. � �i. 'Y�r "trT�l <br /> Plumber's Add <br /> r <br /> ess(Street,City,State,Zip e)V <br /> )1 <br /> VIII Coon /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signature Stamps) <br /> Surcharge Fee) /' -V <br /> ElOwner Given Reason for Denial 3 (/ /(/1° <br /> IX.Conditions of Approval/Reasons for Disapproval / <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />