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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 13"ni e# <br /> isc resin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 +73 tlb ! <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide 1' 3 423 <br /> may be used for secondary purposes Privacy Law,sl5.04(I)(m) Project Address(if different than trailing address) <br /> I. Application Information—Please Print AU Information <br /> Property Owner's Name Parcel# Lot# Block# <br /> j/r Mir ,n Oa O y�d 4 01300 <br /> Property Owner's Wailing Address Property Location U L I <br /> 79,ts" Lane 91Ae RW <br /> City,State Zip Code Phone Number <br /> h, '/., Section VL <br /> Ule1�><<.� en/� S'fg93 yis-��6-gds`S (circle o ) <br /> T yt'7 N; R�_E to <br /> Il.Type of Building(check all that apply) <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City ❑village g7'ownship of QAk/anw <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 El Other Modification to Existing System <br /> B. List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New <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 *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.Dispersallfirreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 3 e o I -- -- <br /> VT.Tank Info Capacity in Total Numbcr Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Nolding Tank 3 6 4�O ..S�A s✓ <br /> Aerobic Treatment Unit L4 <br /> Dosing Clamber <br /> VII.Responsibili Statement-1,the undersigned,assume responsibility for installation or the POWTS shown on the attached plans. <br /> Plumber's Name(Print)L Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 3S' wt6.tsre�i W� Sy�8Q,3 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Sig o Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial 4 ,3000 p7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not kss than 81/2 s 11 Inches in size <br /> SBD-6398(R. 01/03) <br />