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FN Safety <br /> and Buildings Division County <br /> ar <br /> EF 201 W.Washington Ave.,P.O.Box 7162 y P� <br /> iseonsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 �/ , /� r <br /> . Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code;personal information you provide t y <br /> maybe used for secondary purposes Privacy Law,s15.04(1 Xm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name �� a <br /> r Parcel <br /> ens r -.7116 - o3 70 <br /> Property Owner's Mailing Address Property Location SOC [„ <br /> Ess �, /�,« Rd , <br /> City,State Zip Code Phone Number ��'. �A. Section o <br /> 5,P 0O^3ei� /N7- //S�/£�D / ircleo <br /> II. ype of Building(check all that apply) T / N; R!F o I <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use '— c— <br /> ❑State Owned-Describe Use ❑City ❑Villagef�4ownship of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to ExistinyDatelssuedl <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and <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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal AAaPr0P0sed,s1, 1ys; ,1cvevation <br /> ysa 6 v3 �s-6 o <br /> VI.Tank Info Capacity in Total Number Manufacturer teel Fiber Plastic <br /> Gallons Gallons of Units Glass <br /> N9 Existing <br /> Tanks Tanks <br /> Septic or Hnldjno Tank /9 <br /> 0 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plams. <br /> Plumber's Name(Print) Plumber'sSignature MP/MPRS Number Business Phone Number <br /> GrJ�d c kZe&1o/ a-� Z z 7,d9/ 35`9 7-2 6 <br /> Plumm�ber's Address(Street,City,State,Zip Code) <br /> VIII.Coon /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing n ignatur o Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less,than al/2 x 11 inchm in afire <br /> SBD-6398 (R. 01/03) <br />