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v c5— r )) .t ..G 76 t i <br /> Safety and Buildings Division County �1 -0- L-75-5--- <br /> � '��� 201 W.Washington Ave.,P.O. Box 7162 Cane, 0�1 <br /> ® �sc0nsin Madison,WI 53707—7162 <br /> (608)266-3151 Sanitary Permit Number(to be filled in by Co.) <br /> 5,1 too <br /> r <br /> Department of Commerce `j- <br /> _ State Plan I.D.Number <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Property Location <br /> IVA tee SYYleixAK SE 'A NE 'A Section 25 <br /> Property Owner's Mailing Address T 6 N R 7 E <br /> �3 Mil l g. <br /> City State Zip Telephone Parcel# <br /> C r o s s Pawls W 1 28 7q8- 1415 pc- i-- C6C 7- L5l-cl 575-0 <br /> of Building (Check all that apply) Subdivsion Name/CSM# Lot# <br /> 1 or 2 Family Dwelling—Number of bedroom• ((Gird 2 <br /> ❑ Public/Commercial—Describe Use ❑ City ❑ Village Al Township of <br /> ❑ State Owned—Describe Use <br /> III.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 ❑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 /> trNon—Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter <br /> , <br /> Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank CI 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 Appl Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 .'f- 1 i2S ii28 (lit 5' 413,0/ <br /> VI.Tank Info Capacity in Total No. Manufacturer Prefab Site Steel Fiber Pla- <br /> Gallons Gallons of Concr Con- Glass stic <br /> New Existing Units struct . <br /> Tanks Tanks <br /> ,ldingTank tcoo (ow 1 (Vlt_AQE K . <br /> Aerobic Treatment Unit <br /> Dosing Chamber <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 folt/MPRSW No <br /> NY-trey,' W• ( OAKCiL — k) Pil 2201(05 <br /> Plumber's Address(Street,City,State,Zip Code Phone Number(Daytime) <br /> 6515 Hwy. K. Wau vtakee, w( 5-'-S-J1-7 S31-0103 <br /> ,4 County/Department Use Only <br /> proved ❑Disapproved Sanitary Permit F Fee(Intl D to Issued Issuing Agent Signatu -(No S • I.s)L )h�ige e s <br /> ❑Owner Given Le 1 b 4 <br /> Reason for Denial <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 x 11 inches in size <br /> • <br /> SBD-6398(R.01/03) <br />