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Safety and Buildings Division County <br /> IDeparfFentl0f <br /> m 201 W,Washington Ave.,P.O.Box 7162 B4*-na `7`- <br /> Madison,WI 53707—7162 sari p�5�� (608)266-3151 � ii N°mber(to be filled in by Co.) <br /> Commerce /�3 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project:Add,,es,(if different than mailing address) <br /> I. Application Information—Please Print All Information <br /> (Yrot,f /�Gp� <br /> plor <br /> Owner's Name Parcel# Lot# Block# <br /> We s><e//y,ecGl-f 0 — 7- 0 <br /> Owner's Mailing Address Property Location <br /> 73o Jac��.H� Rd sw, ,vw, <br /> e Zip Code Phone Number �• V., Section 7 <br /> vi v (�� S'tQO( 7.5— 6JS86`?`Icircof Building(check all that apply) T 8 N; R �� E oamily Dwelling—Number of Bedrooms � Subdivision Name CSM Number <br /> Commercial—Describe Use WI I erjm V ),0 30 <br /> aewned-Describe Use ❑City_❑village RTownship of bdrwe jr <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. •LV New System <br /> tem <br /> Ys EReplacemmemt System ❑TreatmentlHolding Tank Replacement Only ❑Other Modification to Existing System <br /> B• ❑Permit Renewal on ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before ExpirationPlumber Owner <br /> IV.T of POWTS S stem: Check all that a I <br /> Ar 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 e Pi <br /> V.Dis ersai/I reatment Area Information: P 11 Other(explain) <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 306 . 7 q3A W•� <br /> VI.Tank InfoCapacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Plastic <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> Septic or Holding Tank W0 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <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 <br /> Business Phone Number <br /> ,l,ISBs-/ <br /> Plumber's Address(Str«t,City,State,Zip Code) <br /> 7764 /�wy 3S w�dsFe.- l -5-9 y <br /> p 1, <br /> Coun /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued tamps) <br /> ❑Owner Given Reason for Denial Surcharge Fee) <br /> IX.Conditions of Approval/Reasans for Disapproval <br /> 4li 1 L , 200 ' <br /> BURNETT NZONG NTY <br /> Aresch complete plain(to the County only)for the system on paper not less than 91/2 z 11 inchn in fine <br /> SBD-6398 (R. 01/03) <br />