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U'colf <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 /> lseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department or Commerce [Privacy Law,s. 15.04(I)(m)] (Submit completed form to county if not <br /> Attpch complete plans to the county copy only)for the system,on paper not than <br /> ss 8-1/2 x l 1 inches in size. state owned. c t <br /> County State Sani ❑C k if revisjon to io pp tion State Plan I.D.Number O <br /> �/r4 e. # <br /> L Application Information-Please Print all Information Location: <br /> Owner Name Pro, 1 <br /> p�erty Location <br /> P_ ' l) -e Swl/451-J1/4 se? l N,1e! o W <br /> Property Owners Mailing Address Lot Number Block Number <br /> S- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Nu r <br /> %` ,J W 311 <br /> II.Type of Building: (check one) 152 ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 0 Village <br /> Public/Commercial(describe use): f8'.Town of <br /> Cl State-Owned LD,4111) 'e: 5 <br /> M.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road O/el -35— <br /> A) <br /> 5— <br /> A) 1. New System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing S stem tT 6 O'7 /O rj <br /> B) Permit Number Date Issued <br /> 13A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> gNon-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.Dis ersaVTreatment 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.n.) (Min./inch) Elevation <br /> _30Ga 0 ' 5- — 93- 9 96 <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 /> S L e ADV 0CPAW ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume res ibjli for installation of the POWTS shown on the attached plans. <br /> Plumbers NyncSprint) Plumbers Signature(no ): 00, MP/MPRS No. Business Phone Number <br /> GsA fir*rrG� <br /> Plumbers Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> pp�� ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing t gnatute o <br /> f4pproved ❑Owner Given Initial Adverse Surcharge Fee) }( ^ r ,__6 <br /> vv Determination �P p( (per <br /> IX.Conditions of Approval/Reasons for Disapproval: ' <br /> SBD-6398 807/00 <br />