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_.�"--_ �:itUnly <br /> Safety and Buildings Division unty <br /> 201 W.Washington Ave..P.O.Box 7162 Erni e, <br /> r. <br /> Madison,Wi 53707 7162 Sanitary Permit Number(to be fi eel in • Co.) <br /> � � (608)266-311, 1 1,5g7 Li 7 i Li 7 5 <br /> Department Of Commerce State Plan ID.Number <br /> Sanitary Permit Application 0 a Go 3 2 <br /> in accord with Comm 83.21,Wia.Adm.Code,personal information you Pfovide <br /> may than mailing address) <br /> ny be uacd for accottdary purposes Privacy JAW,s15.84(1}(m) <br /> Project Address <br /> C�fPI'itntAy PO, <br /> 1. Application Information–Please Print All Information _�_ Property Location <br /> Property Owner's Ntaenc <br /> v4 SE —�/a Section — <br /> Propet y Owner's Mailing Address T 5 N R4_a <br /> 90 City A� State zip Telephone Parcel# <br /> _ 1"771 2---DS-6cl—344_-9 q-o f--0 <br /> Type olelyh 1 �I —$Sfu divsion Name/CSM# Lot# <br /> 'iype of Building (Check all that apply) <br /> X i or 21"'amity Dwelling–Number of bedrooms_11 T _ <br /> 13 Publie/Connneraial–Describe Use. --- -- <br /> II City ❑ Village Iil Township of <br /> 17 State Owned–Describe Usc .,_ — -.—_..-- Ord OI''1 <br /> M.Type of Permit; (Check only one box on line A. Complete 1iu if applicable) <br /> New System - . laccment System ❑Treatment/Holding Tank Replacement Only it Other Modification to Existing SystCm <br /> iii' �_„ List Previous Permit Number and Date Issued <br /> �+ ci Permit Transfer to New <br /> illd Pcrntit Renewal ❑Permit Revision °f Owner Plumber Before Expiration <br /> IV.Type of POW'I'S S�+stem: (Check all that Ipylg) ❑Sin Single Pass Sand Filter <br /> U Non-Pressurized In-Ground (:I Mound>24 in.of suitable soil 1:3 Mound<24 in.of suitable soil ❑At Grade <br /> ❑ Constructed Wetland El Pressurized In-Ground D Holding Tank El Peat Filter 0 Aerobic Treatment <br /> nit ❑Recirculating Sand Filter <br /> D Recirculating Synthetic Media Fitter El Leaching Chamber El Drip Line ❑Gravel-less Pipe Other(explain) <br /> V.Dispersal treatment Area Information: Dispersal Arcs Proposed(sf) System Devotion <br /> Design •'1 Appl Rate(gpdat Dispersal Area Required(gq � <br /> Design PPlow(gpd) 1500 15 p 97 v <br /> ("� .4 <br /> No. rvianufaeturer Prefab Site - Steel Fiber Pia- <br /> C:ap�ity to Total Cotter Con- Glass Pla- <br /> VI.Tank Info Gallons Gallons of sttuct <br /> New Existing Units <br /> Tanks Tanks ME-AP X <br /> Wiliariliaril t2 — 12010 i <br /> .,- « . ,. god warn QID[7 ■ ,. <br /> VII.Responsibility Statement-I,the undersigned,assume raspottsibllity for installation of the POWTS shown on the attached plans. /MPl2SW No <br /> Plumber's Signature _ <br /> Plumber's Name(Print) 2,20)g5 <br /> rCAN W W. Me-41,10‘o IWL _�_ _— U)- Phone Number(ba-201 <br /> Plumber's Address(Street,City,State.Zip Code B�FP�Io°� <br /> Gat , 4•}w , K hlAwYnKte , w i 5391/ �# <br /> 3/m.Coon IDe. rtulent Use On .N. _'_ "') <br /> ' p ved 0 Disapproved Sanitary Permit Fcc(inci Date issued g <br /> RPro GW Surcharge Fcc) /�'4 0,.. <br /> ie. 0 . <br /> ❑Owncx Given J31.54 5/31/05 ��., t a∎ u <br /> Reason for Denial Q a <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> .'..,'..;,:r.. :::',7-J. ° "� . <br /> '2r V 9F e <br /> aa ..`ter/. s. ,�, .'i_ ` 75 4: <br /> I I i 1 r only)for the system an I..... f:,:`,1', +-. <br /> .. complete plrtaR(to the County 7) <br /> 1.1.1...17.1111.1.111=1 .. 1a.� <br /> Gana County EnvirfnRliltlt8l <br /> SRn-AI@e oAAM <br />