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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 od G /'fV e� <br /> Vsconsin Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) pp <br /> De artment of Commerce (608)266-3151 5 <br /> Sanitary Permit Application State Plan ITITumber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 1/ 9 39 <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if di erent than mailing address) <br /> I. Application Information-Please Print All Information a - Pyr (V 9-33 _o�_31 <br /> Property Owner's Name (Parcel# Lot# Block# <br /> GJZ D 0 A-rf} ar z <br /> Property Owner's Mailing Address a Property Location /0 C <br /> F/0 Y <br /> C ue/' U/c ,J Z_AJ <br /> City,State Zip Code /, Phone Number A'�J�-A' Section <br /> rk <br /> 'grol 'i Ph-rk /nfu5SY5�7 39 / (circlPff <br /> 11.Type of Building(check all that apply) T N; R E W <br /> Xor2 Family Dwelling-Number of Bedrooms z Sab IM10lrlVaRle CSM Number <br /> ❑Public/Commercial-Describe Use .rat <br /> El State Owned-Describe Use ❑City_❑Village 5Cwnship of <br /> B ew�— <br /> III.Tyrpee. of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �4aov System ❑ Replacement System ❑TreatmenHoldingReplacement Only ❑Other Modification cation to Existing System <br /> B. ❑Permit Renewal 11 Permit Revision ❑ Change ofTO—Pec-1 <br /> it Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber <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 ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 51tg e 1 1 1 -700 97, :F <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 7S-O 7S'0 / <br /> Aerobic Treatment Unit J\ <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pri Plumber's Signator MP/MPRS Number Business Phone Number <br /> �514 /0� z Z 74 y <br /> Plumber's Address(Street,City,State,Zip(rode) <br /> /!y 0.>,- S/ `/ -5//'e -✓ <br /> VIP.CountyfDcpartment Use Only <br /> Approved ElDisapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui go Signora o Stamps) <br /> Surcharge Fee) 7s/' <br /> El Owner Given Reason for Denial g 30 �- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 91/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />