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6�uu w <br /> Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> In accord with Cornet 83.2 1,Wis.Adm. Code PO Box 7302 <br /> See reverse side for instructions for completing this applic <br /> sconsin ation Madison,WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county if not W <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)] state owned. J\ <br /> Attach com Tete fans to the coup co onl for the s stem,on a er not ess than 8-1/2 x 11 inches u size. <br /> Counl, �,� .1� State Sanitary Permit Number ❑Ch if,evi;ion to previous ap 'cation State Plan I.D.Number <br /> may, e, / � �� <br /> Location: <br /> I.A lication Information-Please Print all Information Property Location <br /> Property Oryner me <br /> f -y <br /> / ,.�/ a1)1/4.S3�T Bloc or <br /> N/ �-� Qom// -� '��`J '� � Lot Number Block Number <br /> Property Owner's Mailing Address I �, <br /> 7470 O ti Gil( K Subdivision Name or CSM Number <br /> City,Stat <br /> Zip Code Phone Number e <br /> e 1� <br /> ��b �/J3 <br /> ,4 b -( f IN (� o / ❑City <br /> II.Type of Buil ing: (check one) ❑village <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ttTown of���/S <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-OwnedNearest Roa / L r <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) r3 N„�y <br /> Parcel Tax Number(s) _ _��� <br /> A) I. ❑New System 2. Replacement 3. ❑R placement of 4. ❑Addition tem 3 — �3 <br /> stem Date Issued <br /> Permit Number <br /> B) <br /> ❑A Sanitar,Permit was reviousl issued <br /> IV.Type of POW'C System: (Check all that apply) ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> VL,Non-pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑Pressurized In-ground ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> ❑At- ade <br /> V.Dis ersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.equired Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation Elevation ra e <br /> Proposed Rate(Gals./day/sq.ft.) (Min./inch)7 i ^ 7' <br /> R *� Y <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Gallons Gallons Tanks Con- Con- glass <br /> Information crete structed <br /> New Existing �O <br /> Tanks Tanks ❑ ❑ ❑ <br /> W <br /> f f, c ooa Z5 o 7 6 c�I ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersi ed,assume res onsibili for installation of the POWTS shown MPRvftPRS No. plans. Business Phone Number <br /> Plumber' Name(pnrjV r Plumber sSignal/ure(no ps): <br /> Plumber's Address(Street,City,State,Zip Code) 7 E <br /> VIII.County/Department Use Only Sanitary Permit F (Includes Groundwater Date Issued �� Issuing g t7S� Ps <br /> ❑Disapproved ) <br /> J[Approved [3 owner Given Initial Adverse Surcharge Fee) / 7 <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />