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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O. Box 7162 bone_ 03-Q3 O, <br /> «Conn Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 <br /> Department of Commerce 43 1 <br /> , <br /> Sanitary Permit Application State Plan I.D.Number�i J �.mac_ <br /> In accord with Comm 83.21,Wis.Aden.Code,personal information you provide 1 t' O-S—'W <br /> may be used for secondary purposes Privacy Law,s15.04(IXm) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Property Location — <br /> To rr i ec►e( b ec_iG 5u-) s E ', Section 9 <br /> Property Owner's Mailing Address \- <br /> 1(64 a, F'Sv. �a,tGl,e_f Rd • T .� N R g E <br /> City LA)taff Zip Telephone Parcel# <br /> br or I I53S-7s 1log g3SS/ls-� <br /> Type of Buiktmg (Check all that apply) Subdivsion Name/CSM# Lot# <br /> • <br /> ❑ 1 or 2 Family Dwelling—Number of bedrooms Po,rce_I As. <br /> Public/Commercial—Describe Use 4 tn P Je .5 X 13 ,5Pd 5ZX/S=7 F ❑ Ci ty ❑ village •,gt1 Township of <br /> O State Owned—Describe Use <br /> Ni Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A- ` New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other M•.ifcation to • System <br /> P�. <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of I ❑Permit Transfer to New List Pre ices Pe dnit Numb`etap i Dat¢;l ued <br /> Before Expiration Plumber 11 Owner / / �' ..•:I �. <br /> IV.Type of POWTS System: U* \ <br /> ystem: (Check all that apply) `/ `\� <br /> ❑Non-Pressurized In-Ground 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ',At- e D'( S e Pass Sar1F' <br /> / <br /> ❑ Constructed Wetland 0 Pressurized In-Ground ❑Holding Tank 0 Peat Filter Cn;ter ❑Aerobic Treatment Unit "'9 Sand Fil / <br /> ❑Recirculating Synthetic Media Filter 0 Leaching Chamber 0 Drip Line 0 Gravel-less Pipe 0 Other(explain) ' ..il;-- :,, .;;\ <br /> V.Dispersal/Treatment Area Information: �;.4.- <br /> .,\f <br /> Design Flow(gpd) Design Soil Appl Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System:Elavatidrt/ <br /> 7g c7,5- JSl, 45-4, /Pag')0( C7c.,6</ <br /> VI.Tank Info Capacity in Total No. Manufacturer Prefab Site Steel Fr Pla- <br /> Gallons Gallons of Concr Con- Glass stir <br /> New Existing Units struct <br /> Tanks <br /> Sepik orfleli rienk_...445.5si / NM exx d t <br /> Dosiegaiamber / Meade_ I }° . <br /> VII.Responsibility Statemen-1,foe undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PhtmIzes Name(Prim) <br /> 7s Signature <br /> Stesmer - [1RSWNo <br /> 22711- <br /> Plumber's Address State,Zip Code Phone Number(Daytime) - <br /> (Street.City, uP <br /> N8458 County Rd. 0, Waterloo WI 53594 (920) 478-2379 <br /> VIII.County/Department Use Only <br /> . ❑Disapproved Permit Fee(incl Date Issued Issuin ►° furs �'` s) <br /> 4 GW Surcharge Flee) lej a . ��4 .'`P, � r (� <br /> ❑Owner Given l �,►/, �� A► i;� <br /> Reason for Denial 1070.-- • <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 z 11 inches in size <br /> SBD-6398 at 01/03) <br />