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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 /> isconsin personal information you provide may dart purposes <br /> be used for secondary Madison,WI 53707-7302 <br /> Department of Commerce [ rivacy Law,s. 15.04(1)(m)) (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy Qnlv)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> CountyState emit Number '�]Check i revisio to previous ap lication State Plan 1.D.Number&4— <br /> I.Application Information-Please Print all Informs 'on Location: <br /> PropertyOwner Name /— Property Location <br /> y/ <br /> •�A r 14- Fe r S ; V' A/W 1/4 /Pg1/4 S q T ,N,RISE or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> p'c 13,IX 3Sl &„/-Lot-_ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> fn;I Now#I tu'l - Sly 85-8y/s' Sd S- 3/�8 3.3 r?ckr s <br /> II.Type of Building: (check one) ❑City <br /> lWl' 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): M Town of <br /> ❑ State-Owned Stv l S 3 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 3S <br /> A) 1. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel TaxAmber(s) <br /> S stem Tank Only Existing System I 3,,L Od./60 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ANon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/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.ft.) (Min./inch) Elevation <br /> 443 649 / 7 9s If <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 /> s I` 6 d `fib r S/meq n;`>vt` 1 )a ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Pluryber's ignature( sin s): MP/MPRS No. Business Phone Number <br /> kCAAv) (c,� � S' '715-- 1?6 6— yi 5 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F=(Includes Groundwater Date Issued Issuing Agent Signature s <br /> (Approved ❑Owner Given Initial Adverse Surcharge Fee) 7,57 <br /> \\]] Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />