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�• ui,4 COMPUTER/SCANNED <br /> MA, Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 (3u N n e 7 <br /> consin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4�5 ) 6 <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 /> 1. Application Information—Please Print All Information Se rll H 5 su r, r w Y <br /> Property Owner's Name Parcel# Lot# Block# <br /> /ne,r k J0ti nse H 010 aSq.S-0 7 400 <br /> Property Owner's Mailing Address Ale <br /> Location <br /> *3 00 5. /0 1 h h eSb'/Gt /7 l e• '/4, '/4, Section <br /> City,State Zip Code Phone Number <br /> 57-- f cfeV In Al 5,600%� T `fP N; R I3,ScEoircle o <br /> II.Type of Building(check all that apply) W <br /> 14 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name CSM Number W <br /> 4orS G7-&&-&6 <br /> ❑Public/Commercial—Describe Use { l .5 r) <br /> ❑State Owned—Describe Use ❑City_❑Village 21Township of�.cc kserl <br /> 11I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑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 /> 4 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <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 A060 �vrDO •f ���� <br /> Aerobic Treatment Unit L— <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 /> Plumber's Address(Street,City,State,Zip Code) <br /> 9 -3 .S-- <br /> VIII.County/De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signatu4-1 re tamps) <br /> Surcharge Fee) $ 2 50 40 �L <br /> El Given Reason for Denial (:^i/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> *X: SOIL AB&Mno-t,) cEc,c„s A& r 8ir,�-064110 ofJ 1-0-r &7, �A¢ Seok, ?arc 4v"01- P vE 06 lu PQAP- Is <br /> OA ! � 4v%A the Well a-A test of i,he govice wdl k o" <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 />