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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 - }' t oil - � <br /> i'Isc,c,nsjfl Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> (608)266-3151 T S !4- <br /> Department of Commerce 1) <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 X/d7e <br /> Pro erty Owner's Name Property <br /> A LLocation f <br /> h 'IC �! 411,#)% Se_ % Section 3 la <br /> Property Owner's Mailing Address <br /> 7I(I 71 dt.�f P JC, T 8 N R 1/ E <br /> City' / State Zip Telephone Parcel# <br /> !fir 41.eA d_ Grit S,3 37 -5 • b 54- ( '//- 36,Y- .1171- - d <br /> Type of Building (Check all that apply) Subdivsion Name/CSM# Lot# <br /> I or 2 Family Dwelling-Number o ••. toms OA( /o 531 c) <br /> ❑ Public/Commercial-Describe se ❑ City ❑ Village Township of <br /> ❑ StateiOwned-Describe Use <br /> i-- --____ 4 ' <br /> III. tiff Permit: heck only one box on line A. Complete line B if applicable) ; <br /> • New System <br /> 9 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 Ilor;nit Number and Date Issued <br /> Before Expiration Plumber Owner / . <br /> IV.Type of POWTS System: (Check all that apply) / <br /> likrrNon-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter.. / <br /> ❑ Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter / <br /> ❑Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> / <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 /> YSZ) d. V //lam `/aY /ore - /° t <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 73e4 .Isnk /Oa° / ( /'F 6e I e_ V <br /> Aerobic Treatment Unit V <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P1 1. is Name(Print) P tuber's Si. MP/MPRSW No <br /> 4 <br /> Plumber's Address(Street, City,State,Zip Code ��� Phone Number(Daytime) <br /> 0 e/ i t 1 ' e f s3 .S-) <br /> VIII.County/Department Use Only ;' <br /> Approved ❑Disapproved Sanitary Permit Fee(incl Date Issued Issuing Agent Si:.. re / o Stamps') <br /> GWSur harp FFee) <br /> ❑Owner Given <br /> Reason for Denial p�j h 5}2 c__-.' - —I_ ,.... At.._-IX. Conditions of Approval/Reasons for Disapproval /r <br /> `-lza. 66rr�t r <br /> G <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 />