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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 H4rA Nlt <br /> isconsin Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (bog)266-3151 48 <br /> 157 <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,at 5.04(I)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name v ' Parcel is Lot N Block a <br /> Je vrY /(egobe e.k <br /> Property Owner's Mailing Address Property Location <br /> / 794P -u:(d oen 7%. /1'S• <br /> N��, a , Section 3 f <br /> City,State Zip Cade Phone Number <br /> (a levy -..�(�s lMA1 SSaS'( 6S7dB3�Hdl (circl�) <br /> If.Type of Building(check all that apply) T N; Rl�E o <br /> l or 2 Family Dwelling-Number of Bedrooms d` Subdivision Name �SvlSlvl Number <br /> ❑Public/Commercial-Describe Use firTLa r 7 1/..7F)97 GF V,S /Jy <br /> ❑State Owned-Describe Use ❑City_❑Village Wrownship of Jrn'k-0 1, _nl <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `v ry New System ey y El Replacement System ❑TreatmenUHolding Tank Replacement Only El Other Modification[o 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 /> 15 Non-Pressuriad 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(at) Dispersal Area Proposed(st) System Elevation <br /> 3e o T zo 7 Y.3,1 9/• Y <br /> VL 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 Tank pqL) <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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /?I lk //,,to -IA _r /ZR /fo�c,..--� d)_'1'8S/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,I776a H teless�-r.- <br /> VIII.Count /De artment Use Onl <br /> i Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signatur o Stamps) <br /> Surcharge Fee) <br /> El Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plant(to the County,only)for the system on paper not less than Sin x 11 inches in siu <br /> SBD-6398 (R. 01/03) <br />