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Safety and Buildings Division County <br /> ` MM 201 W.Washington Ave.,P.O.Box 7162 13"r n t <br /> 1.7{i�/lS,ll Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 11 ,I 9F <br /> Sanitary Permit Application States Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(I)(m) Project Address(if different than mailing address) <br /> 1. Application Information—Please Print All information 3560 s, She,,e /FP ' <br /> Property Owner's Name Parcel# Lot# Block# <br /> JR V � ,yi-/l //cff V./we', D/d, 4Y \J-5 0S'S-00 <br /> Property Owner's Mailing Address Property Location GOV tt_ to—r S <br /> 89d( Grad/a C7.-. <br /> '/., Section <br /> City,Stale Zip Code Phone Number S <br /> M�faN N/r Sync/b 7/.f. 30/-/65-7T �dN; R 4 cEcort <br /> 11.Type of Building(check all that apply) <br /> 13 I or 2 Family Dwelling—Number of Bedrooms 4 Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> ❑State Owned—Describe Use (:]City ❑Village gTownship of.Ja.Lkte n <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑New System y F9'Replacement System ❑Treatment/Holding Tank Replacement Only El 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 /> ErNon—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 ❑Gmvel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(s f) Dispersal Area Proposed(at) System Elevation <br /> 600 . -7 R47_7Y6v sr. o <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 /sills <br /> Aerobic Tonga nt Unit <br /> Dosing Chamber <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 Business Phone Number <br /> /t/ Od�,rnyr Ie & / o /c;,+t 1ptIc, o�J Sg's/ 7'S- 8'b G- v/3`7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,,t7760 //, r /.vebsl`ei rrT �y89 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin Signatur tamps) <br /> Surcharge Fee) sdr 5D J' tet' <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less Man gla x 11 inches in use <br /> SBD-6398 (R. 01/03) <br />