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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Al <br /> Visconsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co,) <br /> (608)266-3151 <br /> De artment of Commerce 3 S , ry <br /> Sanitary Permit Application State Plan I.D.Numb(ber lJ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 53 <br /> may be used for secondary purposes Privacy Law,sl 5.04H xm) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name J Parcel# Lot# Block# <br /> k,,� k Asp , - %2 6/ oLIST <br /> y 36,d <br /> Property Owner's Mailing Address y Fh/ Property Location Gov, I 3 <br /> �` j.fi �i✓/ /i/ /ir/N C, ,4/ A (,() r y., 1A Section W—� <br /> IhJ h Zip Code Phone!Number <br /> `J1�p <br /> T �Q N; R/ uEcalegqJe1City,State / <br /> L Ty <br /> of Building(check all that apply) �J <br /> leTor 2 Family Dwelling—Number of Bedrooms 0'"— Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> ❑State Owned—Describe Use ❑City_❑village wnsp of <br /> G <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System / placement System ElTreatment/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 Owner <br /> IV.Tvve of POWTS System: Check all that apply) <br /> on—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.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Sao / 7 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Sim Steel H3er7 Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks ranks <br /> Septic or Holding Tank SO d <br /> Aerobic Treatment Unit <br /> Dosing Chamber S O�Q QO <br /> VQ.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's (Pri ) PIFs Signature MP/MPRS Number Business Phone Number <br /> !!/_// It/w/ z 2- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IL Coun /De artment Use Onl <br /> pproved ❑ Disapproved Sanitary Permit Fee(i cludes Groundwater Date Issued Issuing ent Signature(No Stamps) <br /> Surcharge Fee) Qf�sD I� �y,a3—o Tr �r. _ <br /> ❑ Owner Given Reason for Denial JJJ777 Z� �.t.(X- f 1 YY�t�7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Anach complete plans(to the County only)for the system on paper not less then 812 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />