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Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 Q�v r1 <br /> iseonsln Madison,WI 53707—7162 Sanitary Permit Number(I be filled in by Co.) <br /> Department of Commerce (608)266-3151 i 1 il� <br /> Sanitary Permit Application State TPlan I.D.Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information �) AqS GYbn -errr GK Dr. <br /> Property Owner's Name Parcel# Lot# Block# <br /> 6:4LKyv�Yhassel� 03�-5335-D� �1(5�j <br /> Property Owner's Mailing Address Property Location <br /> f Pmt� Coy,t, tet_ <br /> J 3 91 SI'aft Rd. 3D <br /> a <br /> Zip Code , y Section YS <br /> City,State <br /> Phone Number <br /> 0see6(0L t l 'nt JQS"-dabs (circle one) <br /> 11.Type of Building(check all that apply) T q1 N; R�-$049 <br /> A] or 2 Family Dwelling-Number of Bedrooms � Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City ❑Village gTownship of SW fB.f h✓, <br /> III.Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> A. ❑ New System y gReplacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of El 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 apply) <br /> n-Pressurized In-Ground El Mound>24 in.of suitable soil El Mound<24 in,of suitable soil ElAt-Grade El Single Pass Sand Filter ❑ <br /> onstmcted Wetland ❑ Pressurimd 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(gpdso Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> `1S0 1 7 to 91`3 &ztsr qIll • t <br /> VI.Tank Info Capacity in Tom] Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> NewBusting <br /> Tanks Tanks <br /> Septic or Holding Tank <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 /> Rft:k ,y, k.ns aas �si 7,s=9'6&-(4t25'7 <br /> Plumber's Address Street,City,State,Zip ode) <br /> ,. 7760 Nw 3s W.eA sr;"v - Lvt .ree 9"? <br /> VI <br /> County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signatu o Stamps) <br /> Surcharge Fee) ��( �J��� <br /> El Owner Given Reason for Denial 1r i-W ° o <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> zO <br /> r <br /> 2003 ra <br /> Aftach complete plans(to the County only)for the system on paper not leas than 81/2 x 11 inches in size <br /> 7�AlI�tlr <br /> SBD-6398 (R. 01/03) <br />