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ON COMPUTERISCANNED <br /> Safety and Buildings Division County <br /> I*I-Sconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 Madison,WI 53707—7162 Sanitary Number(to be f led in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application state Plan LD.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) c , <br /> I. Application Information—Please Print All Information <br /> ((z. <br /> A I D 5 0 4-a_ I OD_ <br /> Prop Owner's Name Parcel# Lot# Block <br /> e # <br /> Property Owner's Mailing Address Property Location 0 L� Cj�Ld �— b r, /4, /., Section o2 7 <br /> 114161 <br /> City,State Zip Code Phone Number ,0 5/ <br /> ��� w s p ��y —zz3 KI�irr1s W�r� o �K>° U,&t,t> <br /> A- T N; R E o <br /> II.Type of Building(choWall that apply) <br /> I or 2 Family Dwelling—Number of Bedrooms � QCSM Number <br /> ❑Public/Commercial—Describe Use <br /> ❑State Owned—Describe Use ❑City_❑Villa 'Pip of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ?�Sew System ❑ Replacement System g p y g Y❑ 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 /> n—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/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <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 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume res nsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pri t) Plumber's Signature MP/MPRS Number Business Phone Number <br /> A <br /> lum er's Addres ( treet,City,State,Zip Code) <br /> /`J ^Z <br /> VI I.County epartmenf Use Only <br /> Approved El Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin ge ignatu tamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> W-re: Sall AYe uNosu,4L. SITE Aptis&As r h AA) A;JC1 -r Bc�tcd <br /> DdlosIT Pe Z"6v Y T u bo-D 4AK6. 5irE —51-0?6s 70-WA/ O C'ut"—t- <br /> /k 16 A,0 C A--nsa. <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />