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Safety and Buildings Division County <br /> Wi's <br /> W201 W.Washington Ave.,P.O.Box 7162 Qu r me jq- <br /> eons�n Madison,W[ 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce (608)266-3151 09 3-9 <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,sl 5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information ��� <br /> 3 u mo,,lq <br /> Property Owner's Name pp Parcel# Lot q Block A <br /> /0r lloN Petfric/< 61).- 947-r•ogyod <br /> Property Owner's Mailing Address Property Location <br /> 3`/ 7y /.iir,00„ 6r <br /> City,State Zip Code Phone Number —A, Section <br /> O Hprr W1� S'OI aJ d (cacleo ) <br /> li.Type of Building(check all that apply) <br /> 1 T 4d N; R /S <br /> Eo <br /> PP Y) <br /> ®I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commecial-Describe Use ALU, V V <br /> ❑State Owned-Describe Use ❑City_❑Village®'Township of Jaic /&so y <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑News stem <br /> Y IN 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.T e ofPOWTS S stem: Check all that appill <br /> L9 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.Dis ersaVrreatment Area Information: <br /> ffAaobi.Tmw.n(U.it <br /> (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> • 7 of 9 X311Avofo Capacity in Total NumberManufacturer PrefabSi[e SteelFiber PlasticGallons Gallons of Units Concrete ConsWcted Glass <br /> New ExistingTanks Tanks <br /> g Tanknt Unitr <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 /> Plumber's Address Otneet,City,State,Zip Code) <br /> 7760 h/ '7S ifJ�ds�'�✓ w S5`P9� <br /> VI oun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Penni[Fee(includes GroundwaterMDatcWls�sui5ntigna o Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Drnial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not ins than Sir2 s I I incha in size <br /> SBD-6398 (R. 01/03) <br />