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Safety and Buildings Division County 1 <br /> 201 W.Washington Ave.,P.O.Box 7162 V (N of <br /> Visconsin Madison,W1 53707—7162 Saint ay Permit Number(to be filled in by CoJ <br /> De artment of Commerce (608)266-3151 j)3a <br /> Sanitary Permit Application State PI I.D.Numbgr ec.) <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(I)(m) Project Address(if different than mailing address) <br /> 1. Application Information—Please Print All Information <br /> /VC1CV7-C �1. <br /> Property Owner's Name Parcel It Lotti..- Block# <br /> /►1002.4 ti 43 DTZ X327 03 906 <br /> Property Owner's Mailing Address Property Location <br /> 957 /,/A/ <br /> City,State Zip Code Phone Number ,q� G, V, Section <br /> GreeN W .— ����� $ �$''{2—L circle e) <br /> Il.Type of Building(check all that apply) 2, T � N; R�E oQ <br /> 1 or 2 Family Dwelling—Number of Bedrooms / Subdivision Name CSM <br /> ,/ CSM Number <br /> ❑Public/Commercial—Describe Use L+' I `=1R LaQ P <br /> ❑State Owned—Describe Use ❑City_❑Village rownship ofA�LU,LY* <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)n _ _ — <br /> ANew$ stem <br /> y El 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 /> '.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.Dis ersid/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y% 17 1 14( 657, o p q/If &Vi76A7 90 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New I Existing <br /> Tanks Tanks <br /> Septic or Holding Tank Aq 1000 <br /> Aerobic Treatment Unit W W l <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWfS shown on the attached plans. <br /> Plu er's Name(Print) P1 Signature MP/MPRS Number Busness Phone Number <br /> 5y "141al & 1 / —807 <br /> 0 <br /> Plumber's Address(Street,City,State,Zipe) <br /> 27420 of r .J , W d 51f8 9 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date IssuedIssuing ignatur Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial � /'`Ay �. <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 812 x l l inches in size <br /> SBD-6398 (R. 01/03) <br />