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ke <br /> t 4-'�'7a00 Sti <br /> Sanitary Permit Application Safety&Buildings t o <br /> 201 W. Washingto . <br /> In accord with Comm 83 21,Wis.Adm. Code PO Bo <br /> M�seonsin See reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes Madison,WI 5370 <br /> Department of Commerce (privacy Law,s. 15.04(1)(m)] (Submit completed form to county <br /> PI-VA <br /> tat <br /> Attach complete plans to the county copy only)for the system,on paper Rot less than 8-1/2 x I 1 inches in size. <br /> County Statea it ermit Number C k if revisip,Lt t previo plication State Plan I.D.Numbe� 3 Q <br /> I.AppTication Information-Please Print all Information tt Location: <br /> Property Owner Name Rd*'A4do y f �rS�32¢ Property Location A^ <br /> � R 2r I/4 1/4,S%5 T40,N,46(orjQ <br /> Property Owners Ma ing lkddress Lot Number Block Number <br /> 2� 53 5E <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 54893 S. 415e �.3LyAv w.OFW. raLk <br /> II.Type of Building: (check one) ❑City <br /> Ur I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): 'STown of <br /> ❑ State-Owned ��K �Q <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) I. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s)NN <br /> System Tank Onl Existin S stem 5 <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground �Wmound ❑ Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: 7 <br /> V.Dis ersal 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.R.) (Min./inch) Elevation <br /> 4.50 45� 4s 1. 0 9� 9 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> 1006 V <br /> G <br /> l 00 W� ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumber's Signature(no stamps): MP/MPRS No. r Business Phone Number <br /> mAw UN•, �ZS�J S- _ 10 <br /> umbers Address(Street,City State,Zip Cook) <br /> 27760 3S (A1£BSTgZ W1. S4$93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I ued Issuing A nt Signa re ps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) �O D 1� <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />