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G�1 CDrr�D, <br /> • Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> COgS,/If Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> Coun S Sanitary Permit Number ❑Check if revision to previous application State P an 1.D.Number <br /> I.Airplication Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 'wg a 1/4 1/4,S T ,N, or <br /> Property Owner's Mailing Address Lot Number )494;Lb wmber <br /> ZE3 9 516I,V-Ptizz - 4 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> TAW <br /> WL X4830 is zs , q "' Gr Tb>mp ham <br /> II.Type of uilding: (check one) ❑City /t <br /> ❑Village <br /> 1 or 2 Family Dwelling-No.of Bedro s: <br /> Public/Commercial(describe use): 1r WiDaffm Mown ofc,, �,� <br /> ❑ State-Owned ._7W ` <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. htNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition toP irceljax Nu // <br /> System Tank OnlyExistin System o�b' o— <br /> B) Permit Number p q Date Issued �7 <br /> SanitaryPermit was previouslyissued a, 3 35S 2� t) O S—d `7 S <br /> IV.Type of POWT System:(Check all that apply) <br /> Won-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland yrs <br /> AD Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> L Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> pQ 1-I Zg , '1 e— I ,g 3 , Q <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> a 1v>l1'/ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature nos s): MP/MPRS No. Business Phone Number <br /> 1604ZO l7ft J* 17& 7-7-S9Sf - 4N <br /> Plumber's Address(Street,City,State,Zip C de) <br /> SVIII21160 35- <br /> VIII. <br /> .County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is in Agent Si ature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surchar /ee <br /> Determination ( t O <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />