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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> NOLconsin See reverse side for instructions for completing this application 15 Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 5370y if not <br /> 02 <br /> Department or Commerce [privacy Law,s. 15.04(t)(m)] (Submit completed form to county n not <br /> state owned. <br /> Attach complete plans to the county copy only)for the stem on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary P ❑C rev!#n to previous a lication State Plan I.D.Number <br /> i er <br /> IApplication n a <br /> Property <br /> Property Location <br /> T-69g y A/ o,p1/4 1/4 S 10 <br /> T4D.N, W <br /> properly bwnee.Mailing Adsa Lot Number Block Number <br /> ' 6 f-- t <br /> City,State Zip CodePhone Number Subdivision Name or CSM Number <br /> u t 01 s 4- e ArA A M VV• <br /> II.Type of Building: (check one) U city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Z 13 Village <br /> Town of <br /> ❑ Public/Commercial(describe use): / <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. )iew System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Paine er(s . 1 Z00 <br /> System. Tank OnlyExistin System 6 �b / <br /> 3 . <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> on-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit 0 Recirculating ❑Other. <br /> V.Dis ersai/Treatment Area Information: <br /> 1.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.k) (Min./inch) � .O Elevation <br /> -SM 2.Q z -9 .0 <br /> VI.Tank Capacity in otal #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New " <br /> xisting trete strutted <br /> Tanks Tanks <br /> is 000 I 1000 1 ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned.assume ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's 'gnature(no ): MP/MPRS No.c� Business Phone Number <br /> 1cl♦AIP-0 <br /> umbels Address(Street,City,State,Zip C ) <br /> 2--7-760 S 111 893 <br /> VIII.County/Department 10se Only <br /> ❑Disapproved Sanitary Permit Fee Qpcludes Groundwater Date I ed Issuing7s; t Si ) <br /> A ved ❑Owner Given Initial Adverse Sege Fal Q) D� -��� b/p' <br /> Determination —y� <br /> ZA <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07M <br />