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Safety and Buildings Division Counpr, <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> iseonsin Madison,W1 53707-7162 Sanitary Permit N unbFr(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 �qB* <br /> Sanitary Permit Application State Plan I.D.N mber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide &i <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(i'different than mailing address) <br /> 1. Application Information—Please Print All Information �V� s flj ere lir. <br /> Property Owner's Name Parcel# Lot 61, Block# <br /> Lov tn. Iter z <br /> AM L; / r 03 91i0 a/ 4 <br /> Property Owner's Maili g Address Property Location <br /> �(pa S• SCere Qr; rQ <br /> City,State Zip Code Phone Number 1/� %, Section <br /> ORr,buV W: S�!$3x' <br /> 0 7rS- 66 — 8999 �e) <br /> 70. <br /> ll.Type of Building(check all that apply) T y 0N; R E or <br /> 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Nam C14.� CSM Number <br /> ❑Public/Commercial—Describe Use � JI I <br /> El State Owned—Describe Use ElCit)�EIVillage OrTownship of Qn/d#1 <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑News stem <br /> y T Replacement System ❑Treatment/Holding Tank Replacement Only El other Modificition to Existing System <br /> List Previous Pe it Number Date Issued <br /> B. 13 Permit Renewal El Permit Revision ❑Change of ❑PennitTmnsfer to Ne`y a7 _ 03 <br /> Before Expiration � Plumber Owner �•�{� � / lL� <br /> IV.Type of POWTS System: Check all that a ly) 14 <br /> PNon—PressurizedIn-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑S ngle Pass Sand Filter ❑ <br /> Constructed Wetland ❑Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirci lacing Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) 3ystem Elevation <br /> 300 . 7 �/a 5 Ars-o (70e. y <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Sil Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constricted Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank ra&q <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the aft,ched plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Bus rus Phone Number <br /> /Pe e--44 •at/) � / / �� iI s--Sr6 6- v�s- > <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J6D 1Y3 � GlJ26S)`C/ t7r Sf'�93 <br /> VIIL Count /De artment Use Ord <br /> Approved El Disapproved � <br /> Sanitary Permit Fee includes Groundwater Date sued Iss i e t Signa (No Stamps) <br /> Surcharge Fee) o�v�O�W <br /> 11 Owner Given Reason for Denial (D <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plane(to the County only)for the system on paper not less than Sun x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />