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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin <br /> 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 form 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 11 inches in size. <br /> County / State Sariitary Permit Number ❑Check if revisioq to previous application State Plan 1.D.Number <br /> Rt <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name ` Property Location <br /> 0?1%CL a t ( 'd— J o Y'Y2n404. 1/4 1/4,S 19 T Y0,N,0'E(or) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> o2aoo dri ffa L7- A Y--r <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> New 8r;jAhA " pow SSWL0L ( 657 ) 98sr- G379k. J,tn Hvtlk*,'5 ArXtwallS S„l "A*j <br /> II.Type of Building: (check one) ❑City <br /> W 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ Mown of <br /> ❑ State-Owned .5co+lr <br /> Nearest Road <br /> &%Ao c.kt <br /> Parcel Ax Number(s),,,-ytit'O2.900 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. New 2. El Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> LB) 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 /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: A; U / P7 p eF <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 /> y5Z 37.5 327.Y . 7 9/,r 97, s <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete strutted <br /> Tanks Tanks <br /> S�fi2 /co(> /Goo Lv 1 CS&7 Cbncov ee kb ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) er's Signat o stamps): MP/MPRS No. Business Phone Number <br /> Dori ,Q�f.tt•.�4.,,, as s� ��r -s7,.t- »�.t <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1-vu t/Aya,,.'4 Wr sn*Y3 s (�It er�jt� �elr e 92— '7®aj <br /> )— <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F (Includes Groundwater Date Issued Issuing A ent Si ature Ps) <br /> `Approved El Owner Given Initial Adverse Surcharge Fee 42 <br /> Determination v�Vo /�l 71 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> Co c12e <br /> rh��tr�e ,�s�- chloer Qya�Q - � �n�Q c/ Ffinbers. // or�� <br /> tz bti) a S�T� Ckr('. <br /> n) tJ <br /> C.1 � <br /> SBD-6398(R 07/00) <br />