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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 a r n -ff <br /> 84sconsin <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.Number 90 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s I5.04(1)(m) Project Address(if different than mailing address) r� , <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# Lot# Block# / <br /> Property Owner's Mailing Address Property Location <br /> " CO' /?e( Zip CPhone Number <br /> Code IV N/V4, (y Section of <br /> City, 7 <br /> WP�Sf>°✓ Lt/�� 7 ��J 3 7r� ( ��10�f T�fL N R I, ircle w) <br /> II.Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> ❑l or 2 Family Dwelling-Number of Bedrooms t! <br /> public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village VTTownship of Jac/-son <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ❑New System ❑ Replacement System �Trea[menUHolding 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 a 07a s / <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 11-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/Treat ut Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(sf) Dispersal Area Proposed(at) 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 A <br /> Septic or Holding Tank �.p00 doO 1 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,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 /> frit-k 16okr„ S 124,cA� `�w"�`�,� � _ 22 s"�S/ 7iS-P66-5�is"� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Court /De artment Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuin cut gn o Stamps) <br /> Approved ❑Disapproved Surcharge Fee) / <br /> ❑Owner Given Reasoa for Denial <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Norio: C,&h 4wlw w r2c- luau. is Srx4o qs � � J -L �� <br /> �J �''� <br /> 1.C511T64 -In4r7tt�a USS To C[ Cwv Gt/afa Ya be (kH6r�l. <br /> 7 � j'/ ? 2004 I <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 i4ft RNC TT COUNTY <br /> ZONING <br /> S13D-6398 (R. 01/03) <br />