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' ON COMPUTER/SCANNED <br /> Safety and Buildings Division County ? <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> 1*is �j r 1111 Consn Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> { <br /> Department of Commerce (608)266-3151 "�OSU <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide J�J <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) 91 <br /> I. Application Information—Please Print All Information B t SS 41, Rd <br /> Property Owner's Name —}� Parcel# Lot# '�, Block# <br /> Cyl <br /> J64 n Gusta 3& 03A 17610 Ott 00 <br /> Property Owner's Mailing Address Property Location <br /> P 0$o X 4 7,t <br /> City,State Zip Code Phone Number <br /> %., %4, Section <br /> G t'"v Q SC o /V E io eel 7 (circle) <br /> II.Type of Building(check all that apply) E oRnV, <br /> 1 or 2 Family Dwelling—Number of Bedrooms d Subdivision Name CSM NumberAA// <br /> ❑Public/Commercial—Describe Use !Axq AcuQ 5 <br /> ❑State Owned—Describe Use ❑City_❑Village I?fbwnship of Sw r>-S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, New System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑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 System: Check all that apply) <br /> a 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 ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 0o . ..7 `0� �/3 <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 TOO Roll sk a w <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,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 /> /i is&_ yo kin S I /?le-*- /yo /D"n S )"t.SBS/ 7iS= 96 G -- N/S_7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> )7760 We6<51ee I,/- <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing nt gnalure o Stamps) <br /> Surcharge Fee) �44(41( <br /> ❑Owner Given Reason for Denial ,250 `� <br /> 0 <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 z 11 inches in size <br /> SBD-6398 (R. 01/03) <br />