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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> PIsconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 7a a <br /> Sanitary Permit Application State Plan I.D.Number <br /> 1n accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide 9 <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information �q� L? � 0 <br /> ]� <br /> Property Owner's Name Parcel# Lot# Block# <br /> 6 l rl 1 r {�✓l a rc lei n 6 34 - Sa 19-- Oomo <br /> Property Owner's Mailing Address Property Location av <br /> t*—s t _L ` <br /> ,I-V714-', A66orf A.e S' W/C7 <br /> City,State Zip Code Phone Number V4, —'� Section <br /> le <br /> Al / N S /Q �/� 5,31-10t06 (cEot one) <br /> 11.Type of Building(check all that apply) T 4/ x; R /S E ® <br /> 2rl or 2 Family Dwelling-Number of Bedrooms ISubdivision Name `/ CSM Number <br /> ❑Public/Commercial-Describe Use i-�7 I C S V. )a' e 14 <br /> ❑State Owned-Describe Use ❑City_❑Village Township of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' New System y C1 Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of El 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 ap <br /> PrNon-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)n-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.Dia ersaVTreatmcut Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpds0 Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> ,1 a . 7 yd� 3OL 93- 0 <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 810V ee e .-Z <br /> 11<1 <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 /> v <br /> /S 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> >7 - 2rs— We,6sr° i W-7 53WV7 <br /> VIII oun /De artment Use Only <br /> Approved 11 Disapproved <br /> Sanitary Permit Fee(includes Groundwater DaT Issued Issu' Signam o Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial r <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plum(to the County only)for the system on paper not less than 81/2 x 11 inches to size <br /> SBD-6398 (R. 01/03) <br />