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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 8"r n 60 <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 ,/to G/ 75 <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 /> 1. ApplicationInformation-Please Print All information 3 . <br /> Property Owner's Name Parcel# Lot# s Block# <br /> /Yl;ke Saneeee" tool g, - 9375- 07600 <br /> Property Owner's Mailing Address Property Location <br /> 3o3s <br /> 11, N <br /> City,State Zip Code Phone Number �� —�. Section 7 <br /> IDA nbµa^y WS S'4191307/S-ole-+9- 36Sd 4 / (circleo e) <br /> T 0 N; R 4 E oQ30 <br /> II.Type of Building(check all that apply) <br /> ❑I or t Family Dwelling-Number of Bedrooms Subdivision Name � CSM, /Nu1m/ber <br /> C1Public/CommereS Public/Commercial Use rin CJI'ee4l f/W, V' V, <br /> 11 State Owned-Describe Use ❑City_❑Village®Township of .Ses?Y- <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System V Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification m Existing System <br /> B. ❑ Permit Renewal El 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 /> E• '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(st) Dispersal Area Proposed(st) System Elevation <br /> 6 00 . 7 5P57 86 y 93. 7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Teck 5`00 7.f0 /SSS d. S.Ca w <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 Business Phone Number <br /> /�iG�c yo din s /'Ci oySgS/ lis= 8'66-4iS> <br /> Plumber's Address(Street,City,State,Zip Code) <br /> '7 76 O ?Kw —_2�Lt12b S�Pv WL s` X93 <br /> VIII Count /De artment Use Ord <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issum gen ignature mps) <br /> Approved El Disapproved Surcharge Fee) <br /> El Owner Given Reason for Denial /V✓V (/ I t <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plan(to the County only)for the system on paper not less than 8112 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />