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Safety and Buildings Division County <br /> Ni v r` 201 W. Washington Ave.,P.O.Box 7162 Dan 2 <br /> isconsin Madison,WI 53707—7162 Sanitary Permit Numb (to be filled in by Co.) <br /> Department of Commerce (608)266-3151 '(5-a 5-9 a 0Y-037/3 <br /> Sanitary Permit Application State Plan I.D.Nu <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)) t V�- Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information L'" a pheri4 g tC <br /> Property Owner's Name Property Location <br /> m0' ' .I b,re rSw % Al W '16 Section )L/ <br /> Property Owner's Mailing Address <br /> ' T '] N R 1/ E <br /> C4 S;'l ue- S{oite Consfirut'tid". 3113.2 c f• N <br /> City State ✓ Telephone Parcel# <br /> Cei t e -Groves kv .1i 35".t 7 Oise—olit-14.--4003-0 <br /> Type of uilding (Check all that apply) Subdivsion Name/CSM# Lot# <br /> 1 or 2 Family Dwelling—Number of bedroo 5" 1 0 6 .1 <br /> ❑ Public/Commercial—Describe Use ❑ City ❑ Village 6i(Township of <br /> ❑ State Owned--Describe Use <br /> AP). rove <br /> III. •- 1 .. ••...• /AV only one box on lin . Complete line B if applicable) X <br /> ANew Sy ❑Replacement System ❑Treatment/Holding Tank Replacement Only t I4 . 'f , sting System <br /> • • errmt Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to N , L i Previous Permits • t Issued <br /> Before Expiration Plumber Owner 1/41/ <br /> IV.Type of POWTS System: (Check all that apply) 4 I <br /> Non—Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil : ;t- II Single and ' <br /> CI Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment I d 6 I!' -.. ulating S. • •',I <br /> ❑Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explal 1‘7/701/%, <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Appl Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) " - tern Ele -tion <br /> 600 .y 15 oo I5-0 o /0A to?, ¢ <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 /> /2-8"4 /2r6 I meets('Q , K <br /> Aerobic Treatment Unit /" <br /> Dosing Chamber i <br /> G,9'o Aso l -me�.�� +� <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 MP/MPRSW No <br /> i<eww2 "M gleiQr K,... /F ,v `11'15/ <br /> Plumber's Address(Street,City,State,Zip Code Phone N' ,. (Daytime) <br /> 7 . - I 14 n •!i .L . . ..5--P-- AAA ` S <br /> VIII.County/Department Use Only <br /> .pproved ❑Disapproved <br /> ❑Owner Given Sanitary Permit Fee(incl Date Issued Issuin_Agent Signature . / <br /> �\ G Surcharge Fee) <br /> T <br /> Reason for Denial .31 - ,• <br /> IX.Conditions of Approval/Reasons 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 />