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Safety and Buildings Division County <br /> t 201 W.Washington Ave.,P.O. Box 7162 a f'�t7474 <br /> Madison,on, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ns� <br /> n <br /> Department of Commerce (fig)266-3151 , <br /> � 52 <br /> Sanitary,Permit Application State Plan I.D. Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 1.2 2r(VUJ <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> v� c re� <br /> Property Owner's Name <br /> Parcel X Lot# Block# <br /> Property Owner's Ma fling Address Property Location <br /> 4!V 3 Z L 1.,+k e" <br /> Section �'��� <br /> City,State Zip Code Phone Number 'A'- ' <br /> (circle ) <br /> • T-- N; R/0V E o <br /> II.Tloype of Building(call that apply) <br /> V4_Qr 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use '�� ❑Ci ❑Villa e <br /> ty Pownship of <br /> ; / <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ;ANew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only <br /> 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 System: (Check all that a 1 ) <br /> ❑ Non-Pressurized In-Ground ❑ Mound > 24 in.of suitable soil XMound < 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. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) 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 <br /> Septic or Holding Tank I � <br /> Aerobic Treatment Unit (J <br /> Dosing Chamber <br /> �j <br /> VII.Responsibility Statement- I.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Priv 0 Plumber's Signa MP/MPRS Number Business Phone Number <br /> 76 7 <br /> 1-7"-2 <br /> Plumber's Address(Street ,City,State,Zip Code) IV <br /> X y^ ry &,J 7 <br /> VIII.County/Department Use Only <br /> AApproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing gent Signature(No Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial �,03oo. oo <br /> IX.Conditions of Approval/Reasons for Disapproval <br />