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Safety and Buildings Division County <br /> Ai 201 W. Washington Ave., P.O. Box 7162sconsin 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 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# Lot# Block# <br /> 11 Na r�zell �, q10 4 d`{o�-a5a7 Cil_ �CXJ <br /> Property Owner's Ma iling Address Property Location <br /> l 15 �l N 5�io rc d r &V-q::Z c.o-rS S4(0 <br /> 'A, 'k,Section <br /> City,State // ZZiip Code Phone Number <br /> 6 ra1,i4,,..76V 0s / (circle QQJ <br /> II.Type of Building(check all that apply) Z, T N; R (J E or, <br /> 1 or 2 Family Dwelling-Number of Bedrooms / Subdivision Name CSM Number <br /> ❑ Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village XTownship of"n ."w <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System ❑ Replacement System XTreatment/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 I l I q-83 <br /> IV.Type of POWTS System: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Mound > 24 in.of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Si gle Pass Sand Fillet <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 ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate( at) Dispersal Area Required(st) Dispersal Area Proposed(sf) SystemElevation <br /> 1/ eJJ 6 �o 1 q9, 5 <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 <br /> �9 Tanks `q <br /> Septic or Holding Tank /Ma /000 <br /> Aerobic Treatment Unit �/(/ <br /> (,;;4 ZIN :X1 <br /> Dosing Chamber ®,.1 LOD <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum 's Name(Prin n Plum 's Sit a MP/MPRS Number Business Phone Number <br /> 7o Z� � S L/ 7i5-�66 z 7v <br /> Plumber's <br /> Address(Street , City,State, Zip Coctvp <br /> q <br /> V II. County/Department Use Only <br /> Sa <br /> Approved ❑ Disapproved nitary Permit Fee(includes Groundwater D reissued Issuing gent Signature(No Stamps) <br /> Surcharge Fee' 11- 0� l <br /> ❑ Owner Given Reason for Denial ��JJ �/ q' <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(lo the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />