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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Dane <br /> 0fS,fl Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' ' <br /> �l 'i, (608)266-3151 <br /> , ent of Commerce 21 J State Plan 0.Number <br /> 3 7 <br /> Sanitary Permit Application <br /> ,''mod with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> maybe used for secondary purposes Privacy Law,s15.04(1 Xm) Project Address(if different than mailing address) <br /> n Information-Please Print All Information 2861 Henshue Road <br /> suers Name Parcel# Lot# Block# <br /> ccott&Cheryl Wilson 0610-071-8710-7 <br /> Owners Mailing Address Property Location <br /> r_u, <br /> 861 Henshue Road NW v., NE iS � 7 <br /> SZip Code Phone Number <br /> ,`Madison,WI 53711 575-7790 ��) <br /> T 6 N; R 1V EorW <br /> 1 tType of Building(check all that apply) CSM Number <br /> if l or Family Dwelling-Number of Bedrooms <br /> Convenience Restroom Subdivision e <br /> Metes&Bounds <br /> Public/Commercial-Describe Use <br /> i 8 State Owned-Describe Use ❑aty_❑Vl1age 2Townshtp of Dunn <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> -; A. 131 New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> 1.--- <br /> f... B. El permit Renewal ❑Permit Revision 0 Change of 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> 1V.Type of POWTS System: (Check all that apply) <br /> 0 Non-Pressurized In-0twnd ❑Mamd>24 in.of suitable soil ❑Mound<24 is of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> t. Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter 0 Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter 0 Leaching Chamber 0 Drip Line 0 Gravel-less Pipe 0 Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) - Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(at) Syrian Elevation <br /> 78 0.4 195 198 94.0' <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Teats flake <br /> Septic or Holding Teak 800 800 1 Crest x <br /> Aerobic Tdeetment Unit <br /> Dosing Camber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature DI/MPRS Number Phone Number <br /> 8:94 ev-7_ kmefsen �Tv.e/lAifril 2---26// 608)83.3`-703( <br /> Plumber's Address(Street,City,State,Zip Code) <br /> S,$5 L-iitcolti ii are ov1 WI- .5`3S7ir <br /> VIII.County/Department Use Only 4 <br /> A Sanitary Permit Fee(includes Groundwater Date Issued `fps,:;t t Si_ o S ) <br /> llpprwod 0 Owner Given Surcharge Fee) C� Li y CVO� :�i,..i��,I��" r po <br /> ❑Owner Given Reason for Denial I- I q, v I / i/ V�/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 1 NOV - 8 2006 <br /> i <br /> Attach complete plans(to the County only)for the system on paper not lees than 81/2:1l inches in vizi , ` <br /> L _ <br /> SBD-6398(R.01/03) <br />