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// • • . <br /> - -) IECk ai <br /> ' Division County <br /> -. 201 W. ashin:, .1 ,► ,P.O"Box 7162 F — <br /> Iscons1 Madison, ' I ►:/J7-7162 Sanitary Permit Number(to be filled in by Co.) <br /> -Department of Commerc JUN 9 2oa�°8) .�., IS1 5/8 o 1 6 <br /> __.__._._--- <br /> ' <br /> Sanitary P rmit Applicati n State Plan LD.Number <br /> In accord with Comm 83.2`.,Wis.AdialittitIP,Ipiallitill Mliiiation you provide <br /> may be used for secon >gl p4(IXm) Project Address(if different than mailing address) <br /> .Se ur){• J Pre-G-o t'a.A. <br /> L Application Information-Please Print All Information . <br /> Property Owner's Name Parcel# <br /> (OTT , U J 6-(3L v T7-4 b7(I 25Y -,g'SS-0--0 <br /> Property Owner's Mailing Address Property Location <br /> �-3 ( O' M A I OJ Lot# / Block# <br /> City,State,Zip Code Phone Number 2-S- , <br /> M�� / 66V.7( r7 /""�Y.,S�i/., Section <br /> D e e. _R EL ) c- J 1 • S I '7- ?� T 7 N; R i( E <br /> IL Type of Building(check ail that apply) <br /> Sa=m CSM Number <br /> or 2 Family Dwelling—Number of Bedroo.. J 16 <br /> ❑Public/Commercial—Describe Use Mir <br /> ❑State Owned—Describe Use V ❑City❑Village[Township of <br /> GoTTI <br /> IIL T A. 1 ' I. - heck only one box on line A. Complete line B if applicable) 9fi �� <br /> A ''L1-New System ❑ Replacement S yste m <br /> ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Fxis+ing System <br /> 4 <br /> B- I Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New I' Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> W.Type of POWTS System: (Check all that apply) <br /> 13-1 —Pressurized In-Ground ❑ Mound>24 in.suitable soil ❑ Mound<24 in.suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑Constructed Wetland <br /> Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑Recirculating Synthetic Media Filter <br /> ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.DispersalfTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> C.0o D -y / s-°a / S3 9/- Sl 1'2-1 4yZ a <br /> _ VI Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks _Tanks <br /> Septic 0,44o4 Tank /2 S Z /2 si) l 0 r7(-VI/7'- ( .94-. X <br /> Dosing Chamber Cdted- A <br /> Aerobic Treatment Unit <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum 's Name(Print) PI 's e MP/MFRS Number Business Phone Number <br /> Plum ,�.,�s�� �3/y� <br /> P eez- Address(Street,City',,Sttaat�e,ZZi'p'Code) {' `/� <br /> �-•� t7 9� / 1//f'a ,qer U r 0' ail/t4 ‘3,/ <br /> VIII County Depa .11 ent Use Only <br /> oved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issu-. Issuing •era Signatu•, sirr <br /> Surcharge Fee 3 0 <br /> II Owner Given Reason for Denial a # ♦ h1 _ �V/ <br /> IX Conditions of Approval/Reasons for Disapproval Zvi <br /> j <br /> Attach complete plans(to the County only)for the system on paper not less than 812 z 11 inches in size <br /> eh eC- < X b 11/713 brt3.r.D aZ Sn <br />