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ON COMPUTER/SCANNED <br /> Salcty and Buildings Dnfsion Cuuntti/� <br /> 201 W Washington A%e, P.O Box 716' /JVrNe f- <br /> iseonsinMadison, W1 6 -7162 Sanuary Pennit dumber(tu - tilled in by Co) <br /> Department of Commerce (6i)5)'bn 3151 ,f,ls�,/� 00 <br /> Sanitary, Permit Application Slat- Plan I D Number <br /> In accord with Comm 83_2I.�k is.Adm.Code,personal information you provide s 1::14I -� <br /> may be used for secondary purpose's Privacy Law,sl 5 o-tt 1)(nl) —� <br /> ro3ect Address(ifdlffercnt th mailing address) <br /> I. :lpplication Information—Plcasc Print All Information —53 1(� C� � � e <br /> Property Owner's Name l <br /> Parcel a Lot n Block# <br /> © p 1 v <br /> Property Owner's Mailing Address <br /> Propery Location <br /> l 6 3,70 qA t" ve /j <br /> City,State ZipCode Section_9 <br /> Phone Number <br /> /V circle ) <br /> 11. ypc of Building(check all that apply) H6 �T _y' T�N, R/`J E o� <br /> I or 2 Family Dwelling-Number of Bedrooms �J Subdivision Name CSNI Number <br /> ❑Public Commercial-Describe Use �m vi Cl/ <br /> ❑ f ��Z <br /> State Owned-Describe Use ❑City_❑Village)(Township o i�150 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> .a. <br /> �J New System El Replacement System ❑ Treatment Holding Tank Replacement Only El Other Modification to Existing System <br /> :1 <br /> ❑ Permit Renewal ElPermit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B• <br /> Before Expiration Plumber Owner <br /> 1N-.Type of PORN TS System: Check all that apply) <br /> NNon-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(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(sf) S stem Elevat <br /> y� • 7 6,Y3 ` �0 row gz�7.Tank In Capacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Plastic <br /> Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 000 <br /> Aerobic Treatment Unit V <br /> Dosing Chamber <br /> %IL Responsibility Statement- I,the undersigned,assume responsibility for installation of the PONNTS shown on the attached plans. <br /> Plumber's Name(Print) gnatur �NIPRS Number Business Phone Number <br /> lc�4r10 o3'1c)M��Plum�bff'S <br /> 09 5'I 7/S 86 - / -7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27760 55 l„r ter I;,,J yL�q <br /> VI11.Count,,/De a tment Use Only <br /> lD Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu,ng. e ignature tamps) <br /> Surcharge Fee) q11, 25�� / /� D� <br /> ❑ Owner Given Reason for Denial /f- <br /> I\.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County onl))for the system on paper not less than 81;2 x 1]inches in sit <br /> SBD-6398 (R. 01/03) <br />