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`/� ` /� S ash and Ave., Division County�r <br /> ` � � 201 W.Washington Ave.,P.O.Box 7162 <br /> iscons Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by co.) <br /> Department of Commerce (608)266-3151 544)20 7 W <br /> Sanitary Permit Application State Plann I/D-.9 <br /> In accord with Corton 83.21,Wis.Adm. Cate,personal information you provide (�W�" / ltNt�fl <br /> may be used for secondary purposes Privacy Law,sl5.04(1Xm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print AB Information �� �K//�j F/ <br /> 410 � <br /> Property Owner's Name parcel q Lot N a3 Block M <br /> oDa N 9,b - 3-3 <br /> Property Owner's <br /> ner's Ma flingWAddras Property Location <br /> City,State Zip Cade y Phone Number !f, %,Smtion <br /> r rvUrllPi N � / 696-35Z /(tact <br /> II.Type of Building(check all that apply) T�N; R 1b E XI <br /> 1 or 2 Family Dwelling-Number of Bedrooms 2 S bdivision Name n CSM Number <br /> ❑PubliclCommcrcial-Describe Use q�unl r(/d!' f�%N <br /> ❑State Owned-Describe Use ❑City_❑Village IWownship of 05IQp <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑ Treamtem/Holdin <br /> B Tank Replacement ONY ❑ 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 S stem: (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 Treamtent 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 <br /> QO(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area pro <br /> 33 7 posed(st) System Elevation <br /> Z y2 9 z <br /> VI.Tank InfoCapacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank iwtl ytyrt ' <br /> Aerobic Treatment Unit (•l/ �tl <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility,for installation of the POWTS shown on the attached plans. <br /> Plu 's Name(Prin t) PI s Signa MP/MPRS Number Business Phone Number <br /> To <br /> Plumber's Address(Street ,City,State, Code) <br /> Z7440 Tana, i✓ � Q,4,1",- <br /> VIII <br /> ountyMepartment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater <br /> Date Issued Issu' Signa tamps) <br /> Surcharge Fee) �r 'r <br /> ❑ Owner Given Reason for Denial W 3Zr��� /'}�thK. �� <br /> IX. Conditions of Approval/Reasons for 1Nsapprgval <br /> D Ec6dE <br /> JUN 112010 <br /> Attach complete plans(to the County only)for the system an paper not lest then 81/2 x 11 <br /> SBD-6398 (R. 01/03) ZONING <br />