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Safety and Buildings Division County <br /> Visconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 QWr n -Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 't,I6)S <br /> Sanitary Permit Application State Plan I D.Number \ 1 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide /,3) 7555 W <br /> may be used for secondary purposes Privacy Law,s 15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> a x+64(0 $grlrrlC rT <br /> Property Owner's Name k Parcel N Lot R 7 Block N <br /> Oou 0C. ?nee 0 3y_ q/oo _ a/goo <br /> Property Owner's Mailing Address Property Location <br /> 9583 /,3�KeN r!o��t <br /> City,StateMSS Zip Code Phone Number �• _%, Section <br /> Ya �YJ -$'.S'077 37rrircle one)n nvC Gve ��r T_ <br /> II.Type of Building(check all that apply) N; F !� Eor® <br /> X I or 2 Family Dwelling—Number of Bedrooms Subdivision Name CSM Number <br /> C1 Public/Commercial—Describe Use SunnS I p b <br /> 13 State Owned-Describe Use ❑City_❑Village®Townshipof T-am'e UG <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑News stem <br /> y �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 Wetland ❑ Pressurized In-Ground KHoldingTank ❑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/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(s0 System Elevation <br /> VL Tank Info Capacity in jGall'ons <br /> Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> TanksTmrks <br /> Sepic or Holding Tlc 30o <br /> x <br /> Aerobic Trcatnant Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-f,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature/7^'/ MP/MPRS Number Business Phone Number <br /> RIe-& /�o L./t3 /�u� rtes 811 his BGG - r/is"7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ot7760 HW 3S we bsr`ri �✓^ s� g5? <br /> VITY.Count /De artment Use Onl <br /> Approved ❑Disapproved Sanitary Penmt Fee(includes Groundwater Date Issued Issuing gnatur o Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plane(to dee County only)for the system on paper not Ips 1Wn 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />