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1 Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 O�lie 0'�' °� <br /> VII,seonsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 14-- 463(-1')---Department of Commerce _ 14-- 463(-1')---T <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(lxm) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information g/<Q p e ge9 <br /> Property Owner's Name Property Location T' <br /> R,vtr. 1cQ 00rrkO✓5I AAA/ '/,, 5E '/, Section 36 <br /> Property Owner's Mailing Address T $ N R I! E <br /> "ti ) t ttd,e g(g- <br /> City , State Zip Telephone Parcel# <br /> C' es,i.eio k,S . 3631 0S - ori/- 34y, 1SSD '6 <br /> Type of Building (Check all that apply) CSM# Lot# <br /> /07: 1 or 2 Family Dwelling—Number of bedroo 3....) /b5-vet <br /> ❑ Public/Commercial—Describe Use ❑ City ❑ Village 0r Township of <br /> ag <br /> ❑ State Owned—Describe Use )'r Qi trr es <br /> HI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. fa New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other odification to . - ting System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List.' evious$banter l,Date Issued <br /> Before Expiration Plumber Owner j. N;—"<C`t" <br /> IV.Type of POWTS System: (Check all that apply) 4 <br /> k Non—Pressurized In-Ground ❑Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑ • -Gradt<.w Single P s and Fil \'' <br /> ❑ Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment tllri�y,(Ot rculatini Filter <br /> ❑Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explahi)/,'`�.y< 29 <br /> V.Dispersal/Treatment Area Information: '. �, <br /> Dispersal Area Required(sf) Dispersal Area Proposed(sf) N%Sy ev on <br /> Design Flow(gpd) Design Soil Appl Rate(gpdsf) specs 9 •-,-.4 <.4, <br /> VI.Tank Info Capacity in Total No. Manufacturer Prefab Site Steel ibex Pla- <br /> Gallons Gallons of Concr Con- Glass site <br /> New Existing <br /> Units struct <br /> Tanks Tanks <br /> Septic or Holding Tank /060 l /0 00 ! Meet ell t to <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. MP/MPRSW No <br /> Plumber's Name(Print) Plumber's Signature <br /> /` i2 n n e 1 A Metes-- Phone Number(Daytime) <br /> Plumber's Adams(Street,City,State,Zip Code <br /> 2569 i (/CV✓'1 ir1 Go s ct Done LAJ-T 535?-? <br /> VIII.County/Department Use Only <br /> �tpproved 0 Disapproved Sanitary Permit Fee(incl Date Issued Issuin_ • •M ignatu• o Ai <br /> GW Surcharge Fee / �4,/ (ii <br /> ❑OwnerGivenDb _ 111 /p� `ar, /, > ■ <br /> Reason for Denial D tit <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 /> SBD-6398(R.01/03) <br />