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r <br /> , Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 al tie, 01-(-0g: <br /> � <br /> .�SCOnS'n Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.). <br /> (608)266-3151 <br /> Department of Commerce S (n . <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) ^fPI Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information C� IL a�•V C J <br /> Property Owner's Name Property Location <br /> 301a(14 NW '/. N W Y4 Section 3Z <br /> Property Owner's Mailing Address <br /> T 7 N R 7 E <br /> 4SEG CTH.J <br /> City State ' Zip, Telephone Parcel# <br /> M . Horeb roil -- 55672. 220-5513 oz0-0707- 311- Si-Wo-O <br /> Type of Building (Check all that apply) Subdivsion Name/CSM# Lot# <br /> X I or 2 Family Dwelling—Number of bedrooms 4 ' Csivt <br /> 107b5 3 <br /> ❑ Public/Commercial—Describe Use ❑ City ❑ Village Township of <br /> ❑ State Owned—Describe Use <br /> 'MSS Plains <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 ❑Ol /Ong/.. =.fisting System <br /> C <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New L'• rr s Permit `.. #d 'IA- ed <br /> Before Expiration Plumber Owner v <br /> IV.Type of POWTS System: (Check all that apply) AA <br /> ❑Non—Pressurized In-Ground X Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil '! •t-Gradg I Single Pais Filter <br /> ❑ Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank ❑Peat Fitter ❑Aerobic Treatment .•'t aq�a�F rating San. ilter <br /> ❑Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(caplet 4,0 -01,4. <br /> t <br /> V.Dispersal/Treatment Area Information: e��j e ze d <br /> Design Flow(gpd) Design Soil Appl Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) S -_ Elevation <br /> I.0 (000 4002 sl A i ' <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 /> Septic or Holding Tank (t 3 , -- ic13( 2 Iv1EA De X <br /> Aerobic Treatment Unit <br /> Dosing Chamber (050 — (fit) I X <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature /MPRSW No <br /> Anchew N. trthb1L ■ t__ W 22016,5 <br /> Plumber's Address(Street,City,State,Zip Code Phone Number(Daytime) <br /> cE?:t3 K WGtUrtaKeet Wt 535ci 7 8318103 <br /> VIII.County/Department Use Only <br /> 7 1pproved ❑Disapproved Sanitary Permit Fee(finer Date Issued Issuing Agent Si r: attire • Stamps) , <br /> // GW Surcharge )61 b❑Owner Given Reason for Denial � <br /> IX.Conditions of Approval/Reasons r l isapproval .1 <br /> • <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 x 11 inches in size <br /> SBD-6398(R.01/03) <br />