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Safety and Buildings Division County <br /> Vir 2 01 W.Washington Ave., P.O.Box 7162 J 1IAI 0`f�-OJ 1oq`+/�0nsin Madison,WI 53707—7)62 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 .a� <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 (a- $.- 1-e-4-0,- Ole-0)S t%ty <br /> Property Owner's Name �/ Property Location l I <br /> Fr i t. 1 G k e( L' C 4-(.W1 i 4 v. AA()v. Section /l <br /> Pr Owner's Mailing Address <br /> T 9 N R « E <br /> �a r;c �u J�,� oZ 7 7? �,(urrr�t �''Te. <br /> ity State Z Telephone Parcel# <br /> . Ofek— f1?ft- /f3-(964-4- 6 <br /> T of Building (Check all that apply) Subdivsion Name/CSM# Lot# <br /> 1 or 2 Family Dwelling—Number of bedroo 3 0i.1 ie/1 es,t <br /> ❑ Public/Commercial—Describe Use ❑ City ❑ Village s'Township of <br /> ❑ State Owned—Describe Use -- 7,/ °/1r-li thr / <br /> III.Type of Permit: (Check only one box on line A. Complete line B if.applicable) <br /> / <br /> 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 /> ❑Non—Pressurized In-Ground Xf Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter _ <br /> i <br /> ❑ Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter 0 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 /> 4/3-6 o. (, li 37) ,/, 7, I Ss.V <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 <br /> /616° 40 0 ' Melt J{ - <br /> Aerobic Treatment Unit j ¢ <br /> • <br /> Dosing Chamber / s 0 G.,3--12 l' A <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the`attached plans. <br /> Plumber's Name(Print) • ,.�r=o •. •tire MP/MPRSW No <br /> Nete" Crib 4 , Tr -- lad <br /> Plumber's Address(Street,City,Sta Zip Code �� Phone Number(Daytime) <br /> 7s(l r- a.rlin ef- t tele le)z s35--x, 7/01_-/, . -/ <br /> VIII.County/Department Use y 0 <br /> pproved ❑Disapproved Sanitary Permit Fee(incl Date Issued Issuin Agent Signatu__4 s <br /> �� ❑Owner Given GW Su/rc-barge ) �/ <br /> Reason for Denial 1p71S- 'A -) • ` <br /> I%. Conditions of Approval/Beasons 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 />