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Safety and Buildings Division County <br /> ® 201 W.Washington Ave.,P.O.Box 7162 U�N e��} <br /> isevnsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 �//�� <br /> Sanitary Permit Application State Plan I.D.Number V <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide t <br /> may be used for secondary purposes Privacy Law,s 15.04(1)(m) Project Address(if different than mailing address) v <br /> 1. Application Information-Please Print All InformationC,:2Ip�70 <br /> Prope <br /> C, o� ia(D�O w. Lr sr�CKQ <br /> rty Owner's Name Parcel# Lot# Block# <br /> Carr der !Z3 zoo VAl74 ' <br /> Property Owner's Mailing Address Pr erty Location <br /> ZO t o gel t. ('0T �, ° 13 <br /> City,State ZipCCode Phone Nu;; <br /> ' �'1°. �/4, Section <br /> 3 It <br /> e N ,J�� S� "!(J!" 1;7/7 7 T IC) N; R_I circlep <br /> H.Type of Building(check all that apply) t <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use l LSE"(lf <br /> ElState Owned-Describe Use ❑City_❑Village XTownship of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 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 /> Y Non-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 ❑u <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(sf) Dispersal Area Proposed(sf) System Elevation <br /> SO - 7 YY q 2.0 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constmcted Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank OC6 <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 /> Plr's Name(Print) Plumber's Signature MP,'MPRS Number Business Phone Number <br /> cN 9v( 225 951 715 8V+v d/S7 <br /> Plumber's Address(Sire City,State,Zip Code) <br /> 27 76 w V 35 bye 67z5t 4t)/ <br /> VIII.Court /De artment Use Ont <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date I ued Issuing A ignaturc I mps) <br /> Surcharge Fee) �/ 'Aja]4e_� <br /> ❑ Owner Given Reason for Denial <br /> IX Conditions of Approval/Reasons for Disapproval / <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />