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Safety and Buildings Division County <br /> V <br /> 201 W.Washington Ave.,P.O.Box 7162 RYM'Bseonsin Madls(6on,WI 6.315-7162 SanitaryQenn t Number(to be filled in byCo) <br /> tment of Commerce (608)266 3151 ^lr/p <br /> Sanitary Permit Application State Plan I.Dpum/b/er <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide '/ / , ^ <br /> may be used for secondary purposes Privacy Law,s15.04(!)(m) Project Address(if different than mailing address) v 1 <br /> I. Applicationlnformation-PleasePrintADInformation <br /> Tl -I ': - n5P�, ,�c�.�nct <br /> Properly Owner's Name Parcel# Lot# Block# <br /> Joe <br /> Properly Owner's Mailing Address Property Location <br /> FF`!g3 /f/alsen koectdow Ln• ,1 <br /> City,State Zip Code Phone Number —Ya, Section / <br /> We od ba PI/1/ SS/()L S— (circle one) <br /> II.Type of Building(check all that apply) T 7 N; RAE 011) <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision NsmeT CSM Number <br /> ❑Public/Commercial-Describe Use kOT 3 Ci UL ie t r dd e-LzI4<e. <br /> ❑State Owned-Describe Use ❑City_❑village QTownship of r/aaa16 e k <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A New System Y ❑ <br /> Replacement System ❑7rcatmrnVffolding lank Replacement Only Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer k New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T e of POWT5 S stem: Check alt that a 1 <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 Worland ❑ 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.DigenaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsO Dispersal Area Required(at) Dispersal Area proposed(sl) 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 Tuck 3ood 3000 2 S��w <br /> Aerobic Treannem Unit <br /> Dosing Chamher <br /> VII.Responsibility Statement-I,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 <br /> Business Phone Number <br /> >?/c% ffa kin �? std'.�Sl )ir- 86 c-vis7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> rConditions <br /> 3r" w� s> r. wf S5a873 <br /> eat Use Only <br /> proved Ssndary Permit Fee((ncI des Groundwater Date Issued Issuin gent Signature(No Stamps) <br /> Surcharge Fee) <br /> er Given ReasonforDenial '��roval/Reasona for Disapproval �n \ <br /> �21 <br /> Attach complete plans(to the County only)for the system on paper not Ina than gl/2 x 111 <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />