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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 /> Seonsin See reverse side for instructions for completing this application 15 Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison, to county 7302 <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county isnot - <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 1 inches in size. <br /> Coty State Sanitary Permit Number ❑Check if rev' ion to previous application State Plan I.D.Number <br /> / 1tJP/ <br /> I.Application Information-Please Print all Informa 'o Location: <br /> Property Owner Name ) Property Location 1Z- <br /> .ej O1jk.)5d/j/ LJ1/4/0(54A,SZ23T ,N A(or.Q <br /> perty Owner's Mailing Aiddress Lot Number Block Number <br /> Qom 0 <br /> City,State Zip Code 7Phoneumber Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑City <br /> 154-1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> iTown of <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-Owned <br /> I1I.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> 77 <br /> A) 1. M-New System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tan Number(s� <br /> System Tank Only Existing System I ef 3 4 -,3 <br /> B) 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 12rMound ❑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: <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.R.) (Min./inch) Elevation <br /> 70/ A /Z) s <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 I Tanks <br /> S 5 4 So 7SU ❑ ❑ 13 ❑ <br /> 4.," <br /> ov 5� ❑ ❑ ❑ ❑ <br /> V <br /> A.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 s mps): MP/MPRS No. Business Phone Number <br /> Plum/bees Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Per-((Fee(Includes Groundwater Date Issued Issui ent Si a Mpg) <br /> Approved ❑Owner Given Initial Adverse surcharge Feb9 /f�o /J_ <br /> ^`,f,0.0Determination �C p 1 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />