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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 /> V1.4COnSin See reverse side for instructions for completing this application PO Box 7302 <br /> 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 fort 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 I I inches in size. <br /> County State Sanitary Permit Number ❑Check if revision to prey".000uus 1p kation State Plan 1.D_Number �� <br /> 9/t Y/7 o <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location PO. <br /> .40—r R} <br /> Ta0/ / 'g 0,2 I/4 &;7, T%ONM& or®� <br /> Property Owner's Mailing Address Lot Number Block Number <br /> SO <br /> /V15-7j-0 /70 S7` �l as/y Sr i o0 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> /'1tA mrd k- S� C/6 (6s/ <br /> II Type of Building. (check one) ❑city <br /> B- i or 2 Family Dwelling—No.of Bedrooms: c;2, ❑Village <br /> ❑ Public/Commercial(describe use): IWTown of �/ <br /> L3 State-owned 0'g•k/'t.ro1 <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road(vie- /D/hC 2 d <br /> A) 1. ❑New System 2. IaReplacement 3. n Replacement of 4. ❑Addition to Parce Tax N mber(s) <br /> System Tank Only Existing System] 0_ .301 —8L9- (49 00 <br /> By Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> n Pressurized In-ground O'goldingTank ❑Single Pass n Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit n Recirculating ❑Other: <br /> V Dis rsal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalAtea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> 300 Required Proposed Rate(Gals./da /sq.ft.) (Min.lnch) Elevation <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 structed <br /> Tanks Tanks <br /> o�0 000 <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(no stamps)' [;P/MPRS No. B4siness Phone Number <br /> Plluumbees Address(Street,City,Staten,Zip Code) <br /> ' <br /> VIII County/Department Use Only <br /> ��//�� ❑Disapproved Sanitary Permit F (Includes Groundwater Date Issued Issuing Ag t Sign <br /> go; pproved ❑Owner Given Initial Adverse Surcharge Fee) / <br /> �Y77 Determination- l <br /> DL Conditions of Approval/Reasons for Disapproval: <br />