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Safety and Buildings Division County n J�n,c �� <br /> Visconsin 201 W.Washington Ave.,P.O.Box 7162 D 'VC Madison,Wl 53707-7162 Sanitary Permit Number(to hefilledinbyCo) <br /> Department of Commerce (608)266-3151 State Plan I 495 .2,32—DNumber. . <br /> Sanitary Permit Application In accord with Comm 83 21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy law,s15.04(I Xm) Project Address(if different than m/ai/l.ing addr/ess) <br /> 1. Application Information-Please Print All Informal' <br /> r S • 00 E r 1411 <br /> Pro erly Owner's Name Parcel# 0Lot 3/`D O3 80� Block# <br /> CA rA r C� iSfi�e/ (n3 <br /> Property Owner's Mailing Address Property Location <br /> SY., Section <br /> City,Stale Zip Code Phone Number � <br /> o reit ) <br /> T,jN; R14E or <br /> II.Type of Building check all that apply) Q> <br /> KI or2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑Slate Owned-Describe Use ❑City ❑Villageownship of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System eplacement 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 /> ANon-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(so Dispersal Area Proposed(sf) System Elevation <br /> / . 62 <br /> I.Tank Info Capacity in 4, M <br /> Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> i� <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 plans. <br /> Plumber's Name(Print) Plu tier's Signatur MP P$SNyxnber�� Business Phone Number <br /> U D (o��)) �7[� <br /> Plum er' Address( eet,Ciry,State,Zip Code) or <br /> VII .Court Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dale Issued Issui Age ignalure tamps) <br /> Surcharge Fee) �cJ� 9,3;06 <br /> /I-rte or0 <br /> ❑Owner Given Reason for Denial J 1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Aaach complete plana H.the County only)for the system on paper not less than al/S x 11 inches i.siu <br /> SBD-6398 (R. 01/03) <br />