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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Q4,- <br /> Vp1sconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 x-722 9 <br /> 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,sl 5.04(1)(m) Project Address(if different than mailing address) <br /> 11 <br /> I. Application Information-Please Print AB Information <br /> .(9v 5w0ei- Rcl. <br /> Property Owner's Name - Parcel# Lot# / Block# <br /> DanSrrdnG! ..t.f7' 6U it 07 O 800 <br /> Property Owner's Mailing Address PropMy Location /'_V�(it g, <br /> g .(.O-0- s/Q. /1C) (vit <br /> City,State Zip Code Phone Number - ��' - —y'' Section 7 <br /> t- Fat,1 MV SS//9 6S7 77y- 6937 T 40 N; R /y(cir oe e) <br /> 11.Type of Building(check all that apply) <br /> 1 or 2 Family Dwelling-Number of Bedrooms d. Subdivision Name CSM Number` � , <br /> 13Public/Commercial-Describe Use J <br /> ❑State Owned-Describe Use ❑City_❑Village 13Township of.&c.kfan <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System .Replacement System ❑Treatment/Holding Tank Replacement Only ❑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 Owns <br /> IV.Type of POWTS System: Check all that apply) <br /> KNon-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in,of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Consbucted Weiland ❑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.Die ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpds0 1 Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> 3e, I • A7 7S0 7.r0 9,t.S 94.,t 9S:r <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Ifiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 7.50 >SO <br /> Aerobic Treatment Unit <br /> Dosing Chamber S100 <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 1?ek- /r/i :nl ��-cc7r.a� 4.)6-S'5/ 7/S%8r667 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> e( 7760 9,y w8Efs74C/ W_Z_ 8'93 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date IssuedIssuin t Signature mps) <br /> ��- ,(A1' frUJ C <br /> El Owner Given Reason <br /> Fee) to � T Reason for Denial 7Jt/ T <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 x 11 lather In sirs <br /> SBD-6398 (R. 01/03) <br />