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Safety and Buildings Division County p <br /> vmg� 201 W.Washington Ave.,P.O.Box 7162 Dkr n li}- <br /> W isconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by C <br /> Department of Commerce (608)266-3151 44,5&9,5 t. a 3_� <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 93.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sI5.040)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Informationw <br /> (--e c,) 7-m1I <br /> Property Owner's Name Parcel# Lot#/fS/ifi'(r Block# <br /> a HocvArX 0 <br /> 1 <br /> o1, �Ta7s, —SOU <br /> Property Owner's Mailing Address Property Location <br /> IS A s I. P/ace /✓• v �f <br /> City,Slate Zip Code Phe Number <br /> on *� , N6 '/., Section AX a <br /> Okkdal,o I1I/V f'S/pig (a5-1- 739- 89/$ cucleone) <br /> R.Type of Building(check all that apply) t� T qL N; R / E o& <br /> 91 or2Family Dwelling-Number ofBedmoms T Subdivision Name CSM Number <br /> / <br /> ElPublic/Commercial-Describe Use 1-CS AP54 1 b I/, V. <br /> ❑State Owned-Describe Use ❑City_ Village 197rownship of Jaokion <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ,Q New System ❑ 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.Type of POWTS System: Check all that apply) <br /> KNon-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 Cl Other(explain) <br /> V.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(si) Dispersal Area Proposed(sf) System Elevation <br /> 300 .7 ya 9 43A 9x. 6 <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 /> Scptic or HoldngiTank POp <br /> Aerobic Treatment Lou <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,spume 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 /> R fLk. 3- CJS/ 7�.�r`l(e e,— 91S 7 <br /> Plumber's Address(Street,City,State,Zi Code) <br /> ,� 77co /-1 w 3.E Webster <br /> VIII.Court /Dnartment Use OnlApproved provedSanitary Permit Fee(includes Groundwater Datc Issucd Issuin t Sigoatu o Stamps) <br /> Surcharge Fee) <br /> r Given Reason lfr7Dn ��� ^,3�iU 03 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not icsa than 81/2 x 11 in<hea io sire <br /> SBD-6398 (R. 01/03) t�CL 5 �(-e,Sf <br />