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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 /> `rscens"nSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)) (Submit completed form to county if not <br /> state owned. <br /> Attach omso <br /> lete lana to the coup co onl f the s stem on a t less than 8-1/2 x I 1 inches in size.State Sanitary vics�n vv 1 <br /> . .":. i1 <br /> lication State Plan <br /> Number <br /> I.Application Information-Please Prints Information Location: <br /> PropeK►ly <br /> G6c' r-� A Owner Name /� Property Location <br /> ' I /� RS or <br /> Progeny Ownd1/4 1/4,S T ,N <br /> s Mailing Address 'A`'' Lot Number Block Number <br /> City,StateZip t-�e Phone Number Subdivision Name or CSM Number <br /> �oG s 6 S i ys�-ss�� <br /> OU <br /> r14NJ <br /> II.Type dr Building: (check one) 3 ❑city <br /> VoL 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Mown of.. <br /> -y <br /> ❑ State-Owned i V A"Gk5r",j <br /> Ill.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> U er �.��✓ rte.��✓ <br /> A) 1. `)KNew System 2. E3 Replacement 3. 1:1 Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System O S6 �/av <br /> B) ❑A Sari Permit Number Date Issued <br /> Permit was viousl 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.DIs ersal/Trestment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 1 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Pro sed Rate(Gals./day/sq.fl.) (Min./inch) Elevation <br /> S^U � 977.7 —95 <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�c Derylead s ❑ ❑ ❑ ❑ 94 <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersigned,assume res nsibili for installation of the POINTS shown on the attached lana. <br /> Plumber's N � Plumbers Signature(nos ): MPIMPRS No.��/ B3 !`how Number <br /> 7�'� -2p <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ef p S`/ S�//� GN <br /> VIII.County/Department Use Only <br /> ,,� ❑Disapproved Sanitary Permit FFO(Includes Groundwater Date Iss 16, Issuing S' ps) <br /> 10 Approved ❑Owner Given Initial Adverse Sege Fee)f���f� <br /> Determination v o <br /> IX.Conditions of Approval/Reasons for Disapproval: / <br /> _)�_ 44�i 11 at f obserVa�b�O f 5 ref U.Y� I (�W2+� ce l� <br /> SBD-6396 R07100 C <br />