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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> ` iscon i p Madison,8) 53707 6-3151 7162 Sanitary Permit Nt)mtb,7er([q be filled in by Co.) <br /> V ■.�7 I■ (608)266-3151 jl(v�`J�%` � _/7L <br /> De artment of Commerce / <br /> State Plan I.D.Number <br /> Sanitary Permit Application �Z8 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,at 5.04(Ixm) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information f—1L M L <br /> a E <br /> Property Owner's Name � P 1# Lot# Block# <br /> Ne ' - ad- tA l -/8 2 <br /> Property Owne's Mailm ddress Property Location / <br /> l —V% _'/., Section / 3 <br /> City,State Lip Cade Phone Number <br /> (circle <br /> one) <br /> -ell J ? -Z T�N; R r <br /> Me 12 tiding(check <br /> yyyggqall that apply) Subdivision Name CSM Numbs <br /> Hyl or 2 Family Dwelling-Number of Bedrooms <br /> Public/Cotnmeroial-Describe Use C m G/. C 2l s-�f <br /> ❑State Owned-Describe Use (]City_QVillageAownship of sGb <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. (]New System IR Replacement System ❑TreatmatNHolding Tank Replacement Only ❑Other Modification to Existing System <br /> B. 13 Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T e of POWTS S stem: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Motmd>24 N.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Welland P&Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber D Drip Line U Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersaVfreatment Area Information: C <br /> Design Flow(gpd) Design in Application Rate(gpdst) Dispersal Area Requited(sf) Dispersal Area Proposed sf) System Elevation <br /> 750 _ 7 I07).'Z ❑ I O'M5 I . 2 <br /> VI.Tank Info Capacity in Total Number Mmtutaeur0fcato rate Constructed d Steel Fiber Plastic <br /> Gallons Gallons of Units <br /> Glass <br /> Nees Existing <br /> Tanks Tanks <br /> Septic or Holding Tank LOC(] ) <br /> Aerobic Treatment Unit <br /> Dosing Chamber 1000 <br /> LA V— <br /> VII.Responsibility Statement-b the undersigned,assume r asibinty for installation of the POWTS shown on the attached plaws. <br /> Plumber' ame(Print Plumber's Si MP/MPRS Number Business PhonoNumber <br /> 01 ��� e a.�c I I SSD -3 ?1,5-- 3Y93 <br /> Plumbers Address(Street,City,State,Zip Code) I <br /> L 19 e4 /� <br /> VI .Cozen /De artment a Onl <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuin Signatu Stamps) <br /> Approved ❑Disapproved Surcharge Fee) 2 ` <br /> C1 owner Given Reason for Denial C` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plow(to the Comty only)for the system on paper rat leu iWn 81/2 x it inches im rise <br /> SBD-6398 (R. 01/03) <br />