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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 U ej+- <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 ` <br /> Sanitary Permit Application State Plan I.D.Number 1X�nJ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide = 1 <br /> may be used for secondary purposes Privacy Law,aI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information , ) j�nA '�5 <br /> Property Owner's Name - Paarrcelr#r} Lot# � /II Block#\i..l <br /> a V W im , N c)/Z ,75' O <br /> Property Owner's Mailing Address Property Location <br /> Ar- NW <br /> City,State Zip Code Phone Number �•. �•. Section <br /> 5E or o <br /> II.Type of Building(check all that apply) <br /> VT4/0N; RE or ✓ <br /> 1 or 2 Family Dwelling-Number of Bedrooms z 7 Subdivision Name / CSM Number f,� <br /> 13 Public/Commercial-Describe Use L"u �5�'�C nC.K.9 ' V.V, <br /> ❑State Owned-Describe Use ❑City_ Village%Township of 74q <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. R New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. El Permit Renewal ❑Permit Revision Ll Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that ap <br /> N 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 ersaareatment Area Information: <br /> Design Flow(gpd) Design Soil Aoication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 1150 • h 900 qoo <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 F•/T <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signature MP/MPRS Number Business Phone Number <br /> r Aw t 2725-65- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 - w 6s,�v w: kBq <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued IssuingpSi90ifN0 Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> OCT 2 8 2004 <br /> Attach complete plans(to the County only)for the system on paper not less than 81/1 x 11 inM eTT COUNTY <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />