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Safety and Buildings Division County <br /> ` ` M 201 W.Washington Ave.,P.O.Box 7162 IFk r n C <br /> +y'COry�,n Madison,WI 53707-7162 Sanitary PermitNumber(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 9 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 5 <br /> may be used for secondary purposes Privacy Law,sl 5.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information—Please Print All Information 39/S CO t(d 14 <br /> Property Owner's Name Parcel# Lot# Block# <br /> fou �tiPfhuf aia-ala 1 -o�-�toa <br /> Property Owners Mailing Address Property Location V4, <br /> CA Ga do ser La.. P 2W3 3 / Iv <br /> City,State Zip Code —�� —1/4, Section W <br /> Le//wpn ei /(/ s-S/lO Phone Number <br /> � i 10 ircleone) <br /> II.Type of Building(check all that apply) ; R Eo(5) <br /> / r <br /> C/V <br /> 19 I or 2 Family Dwelling-Number of Bedrooms Subdivision <br /> V <br /> siion1 �OName CSM Number O <br /> 11 Public/Commercial-Describe Use 0.511 , 3-1 rOtJ <br /> 11 State Owned-Describe Use ❑City_❑Village Township ofp.�'-ion <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑News stem a IacementS stem <br /> Y � P Y ❑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 /> ❑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 ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.DesersaVrEeatmen!Area Information: <br /> Design Flow Vill Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> jAmbjicTrcja1= t <br /> To Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tonks <br /> nk iii 3333 <br /> nit <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 /> Rtr le y k,.r s ys Vis, lir-�66-4ir7 <br /> Plumber's Address street,City,State,Zip Code) <br /> 01 7 7A60 H 3-_j- <br /> VIII. <br /> SVIII.Coun /De artment Use OnI <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes GroundwaterjjDat�elsWsuedlssuing ignature tamps) <br /> Surcharge Fee)❑Owner Given Reason for Denial U 457IX.Conditions of ApprovaVReasons for Disapproval <br /> L�xlsr/h� TuK T D� Pli>AY.Gy hheuoouEOp 6u RE <br /> Attach complete glom(N the County only)for the synem on paper not[as than SM x I I inches in firs <br /> SBD-6398 (R. 01/03) <br />