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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O. Box 7162 <br /> Madison, <br /> isconsin on, WI 53707-7162 Sanitary Permit Number(m be filled in by Co.) <br /> Department of Commerce (608)2663151 q5 ,2 7 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis. Adm. Code,personal information you provide /270'937 <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print AB Inf armatioo ^(/O u n t l• <br /> Property Owner's Name Uv Parcel N lot N 7 Block M <br /> rrt L �SS6 O 3-2 9 0 2 3 Yd <br /> Property Owner's Ma iling Address Property LocationPG/ <br /> r ' q <br /> G.�dr C i 11-CQ NL u/UE u,Section� <br /> City,State Zip Code Phone Number <br /> r / (circle one) —' <br /> r /n n.) Ss3 ,C T,7/ N: R�Eo( Q' <br /> 11.Type o uilding(check all that apply) r <br /> /7,��,u" or 2 Family Dwelling-Number of Bedrooms Supdirieiae-Name o CSM Number Q <br /> 0 Public/Commercial-Describe Use O / <br /> ❑Sate Owned-Describe Use ❑City_❑Village;dT0wnship of <br /> ¢tiJOI_r— <br /> III.Type of Permit: (Check only one box on line A. Complete fine B if applicable) <br /> A. phew 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 Owner <br /> IV.Type of POWTS System: (Check all that apply) <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 Wedand ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Lice ❑Gravel-less Pipe ❑Other(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpds0 Dispersal Area Required(s0 Dispersal Area Proposed(sf) System Elevation <br /> so / S 366 310d 99, S <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Stcel Fiber Plastic <br /> Gallom Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Hotding � fs'Q <br /> -- <br /> Aerobic Tmanment Unit <br /> Dosing Clamber s <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plain. <br /> Plumber's Name(Priv t) I Plumber's Signa core MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street ,City,State,Zip Code) <br /> 11 <br /> 6X S/ f/r^ t...J G✓ S 7 Z <br /> VIII.Counity/Department Use Only <br /> ,,,� Sanitary Permit Fee(includes Groundwater Date Issued luu' A Si No Sumps) <br /> Ia Approved ❑ Disapproved Surcharge Fee) 44 <br /> ❑ Owner Given Reason for Denial W DAA <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system an paper not las than 8112 z 11 inches in size <br /> SBD-6398 (R. 01/03) <br />