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O'�2a0. ao <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> NviseonsinSee 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 /> Attach complete plans to the county conv onl for the s stem on paper not less than 8-1/2 x 1 I inches in size, slate owned. Cl . <br /> County State Sanitary Penni Nu Levi;ipn two prev'ous a lication State Plan I.D.Number <br /> I.A cation Information-Please Print all In or atioo o (/ Location: <br /> Property Owner Name Property Location <br /> TQKNJ ��1 CCD <br /> Property Ownere Malong Address 1/4 1/4 S 6 T ,N )�� a W <br /> Lot Number Block Numbe <br /> S �i4s,�nIT' RD S. .�. � <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> NO N 5501 5 z- <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No,of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): VkTown of <br /> ❑ State-Owned Ru <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. J�New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Pay�yl, Numbers) <br /> System Tank Only ExistingS tem (JLet j� D3 Wo <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IN.Type of POWT System:(Check all that apply) <br /> INNon-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/Treatment Area IntormatIon: <br /> I•Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> /I yy� Required3 Proposed Rate(Galslday/sq.R) (Min./inch) Elevation <br /> ��J 4$ . 7 96 a q7. Iq S J. 10D <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 /> Tattks Tanks <br /> q68 -- Q68 Kew ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> ::4 <br /> I,the undersi ed,assume res ibili for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumbers Signature(n tamps); MP/MPRS No. Business Phone Number <br /> It z2sss� is- g6(;- �IS7 <br /> umber's Address(Street,City,State,Zip ode) ,( <br /> '1'1100 W1. 5442013 <br /> VIII.County/Department Ifse Only <br /> ❑Disapproved Sanitary Permit F (Includes Grmmdwater Dat=ls;,ed <br /> Issuing Ago t Sitamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee)Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />