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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 A Prefrfqeff— <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> NVisconsin <br /> Department of Commerce (608)266-3151 438335 9--) <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 Address(if different than mailing address) <br /> I. Application Information-Please Print All Information *A 3 <br /> Property Owner's Name <br /> �� Parcel# Lot# �J Block# <br /> NN'e 1312 yZ/ 01,600 <br /> Property Owner's Mai1132 ling Address Property <br /> Property Location <br /> �(J5G / l�tG C� V„�.. coT <br /> City,State I �yJ Zip Code Phone Number L/ �� '/., Section <br /> Z04t°Uf Ile / ///V• SS//3 T YON; R /5 Eotirc �t ) <br /> H.Type of Building(check all that apply) <br /> 7 1 or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use "`�I _-S cs it `qD, <br /> ❑State Owned-Describe Use ❑City ❑Village ZTownship ofjqek <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 o=0=1 nsfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber <br /> IV.Type of POWTS System: Check all-that appl, <br /> 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.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) Systetp,Elcvation U <br /> Gov 6pa rnt /GBq•7lower8g,z <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 Tank 71 r <br /> Aerobic Treatment Unit <br /> Dosing Chamber nA — H_ I <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW' shown on the attached plans. <br /> Plumber's Name(Parent) tuber' Signal r MP/MPRS Number Business Phone Number <br /> IID�rIC/C !ro lcin S d• J, 4 715'-• 9(o(r K9-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 4.7760 14ty 35' W•ebsl4Yr 1,V S'99p9_�, <br /> I.County/Department Use Only <br /> Approved El Disapproved Sanitary Permit Fee includes Groundwater Date Issued Issue t Sign o Stamps) <br /> Surcharge Fee) , <br /> ❑ Owner Given Reason for Denial t� ��> ( 0 3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in sire <br /> SBD-6398 (R. 01/03) <br />